Provider Demographics
NPI:1497126775
Name:BAGLEY-AYRES, DAMON (CPO)
Entity Type:Individual
Prefix:
First Name:DAMON
Middle Name:
Last Name:BAGLEY-AYRES
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4611
Mailing Address - Country:US
Mailing Address - Phone:601-815-4844
Mailing Address - Fax:601-815-4592
Practice Address - Street 1:777 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4611
Practice Address - Country:US
Practice Address - Phone:601-815-4844
Practice Address - Fax:601-815-4592
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist