Provider Demographics
NPI:1902435118
Name:THE MANE PHYSICIAN
Entity Type:Organization
Organization Name:THE MANE PHYSICIAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAMALA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHISM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:769-487-4187
Mailing Address - Street 1:428 HIGHWAY 6 E # 217
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606-3000
Mailing Address - Country:US
Mailing Address - Phone:662-262-5711
Mailing Address - Fax:
Practice Address - Street 1:94 SPAIN DRIVE
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901
Practice Address - Country:US
Practice Address - Phone:769-487-4787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier