Provider Demographics
NPI:1881975621
Name:MEDICAL MALL HEALTH SERVICES, LLC
Entity type:Organization
Organization Name:MEDICAL MALL HEALTH SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:C
Authorized Official - Last Name:BARDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-448-2983
Mailing Address - Street 1:2820 BLADENSBURG ROAD, NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-4101
Mailing Address - Country:US
Mailing Address - Phone:202-448-2983
Mailing Address - Fax:
Practice Address - Street 1:450 WOODROW WILSON DRIVE
Practice Address - Street 2:SUITE 499A
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39312-4101
Practice Address - Country:US
Practice Address - Phone:601-500-7709
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center