Provider Demographics
NPI:1861715534
Name:MISSISSIPPI ASTHMA AND ALLERGY CLINIC, P.A.
Entity type:Organization
Organization Name:MISSISSIPPI ASTHMA AND ALLERGY CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-354-4836
Mailing Address - Street 1:1513 LAKELAND DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4829
Mailing Address - Country:US
Mailing Address - Phone:601-354-4836
Mailing Address - Fax:601-354-2619
Practice Address - Street 1:2886 SOUTH LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-7905
Practice Address - Country:US
Practice Address - Phone:601-354-4836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSISSIPPI ASTHMA AND ALLERGY CLINIC, P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-03-09
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09 00008210174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty