Provider Demographics
NPI:1063659340
Name:MALL SERVICES, LLC
Entity Type:Organization
Organization Name:MALL SERVICES, LLC
Other - Org Name:809 CONVENIENT CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:601-982-0673
Mailing Address - Street 1:350 W WOODROW WILSON AVE
Mailing Address - Street 2:SUITE 615
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-7681
Mailing Address - Country:US
Mailing Address - Phone:601-982-0673
Mailing Address - Fax:601-982-0459
Practice Address - Street 1:809 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2604
Practice Address - Country:US
Practice Address - Phone:601-982-0673
Practice Address - Fax:601-982-0459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP320574172V00000X
MSR656046363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115980Medicaid
MS08406271Medicaid