Provider Demographics
NPI:1306414412
Name:MANGUM MISSISSIPPI TRANSPORT LLC
Entity Type:Organization
Organization Name:MANGUM MISSISSIPPI TRANSPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:DEANES
Authorized Official - Last Name:MANGUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-605-0382
Mailing Address - Street 1:29680 HIGHWAY 50 E
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39773-5589
Mailing Address - Country:US
Mailing Address - Phone:662-605-0382
Mailing Address - Fax:
Practice Address - Street 1:26237 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:MS
Practice Address - Zip Code:39773-2749
Practice Address - Country:US
Practice Address - Phone:800-982-3590
Practice Address - Fax:800-982-3590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)