Provider Demographics
NPI:1235845892
Name:SKY INTEGRATIVE MEDICAL CENTER
Entity Type:Organization
Organization Name:SKY INTEGRATIVE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAMEKIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:601-617-7717
Mailing Address - Street 1:408 FONTAINE PL STE 104
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-5189
Mailing Address - Country:US
Mailing Address - Phone:601-617-7717
Mailing Address - Fax:601-398-0381
Practice Address - Street 1:408 FONTAINE PL STE 104
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-5189
Practice Address - Country:US
Practice Address - Phone:601-617-7717
Practice Address - Fax:601-398-0381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06454351Medicaid