Provider Demographics
NPI:1487201372
Name:CALEB MOUNTAIN CLIMBING WHOLISTIC INTERNATIONAL CENTER LLC
Entity Type:Organization
Organization Name:CALEB MOUNTAIN CLIMBING WHOLISTIC INTERNATIONAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:Y
Authorized Official - Last Name:TAH-CLAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:601-606-5771
Mailing Address - Street 1:610 ADELINE ST STE 1A
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-3875
Mailing Address - Country:US
Mailing Address - Phone:601-606-5771
Mailing Address - Fax:
Practice Address - Street 1:610 ADELINE ST STE 1A
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-3875
Practice Address - Country:US
Practice Address - Phone:601-606-5771
Practice Address - Fax:800-489-0211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-24
Last Update Date:2019-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122708Medicaid