Provider Demographics
NPI:1801515622
Name:AT HOME PRIMARY CARE OF MS LLC
Entity type:Organization
Organization Name:AT HOME PRIMARY CARE OF MS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:DELORIS
Authorized Official - Last Name:SLADE
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP
Authorized Official - Phone:601-270-1009
Mailing Address - Street 1:295 ARCHIE SMITH RD
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-9322
Mailing Address - Country:US
Mailing Address - Phone:601-207-1009
Mailing Address - Fax:
Practice Address - Street 1:295 ARCHIE SMITH RD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-9322
Practice Address - Country:US
Practice Address - Phone:601-207-1009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-24
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care