Provider Demographics
NPI:1568089993
Name:MIDSOUTH INTEGRATIVE MEDICAL, INC
Entity Type:Organization
Organization Name:MIDSOUTH INTEGRATIVE MEDICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MEAGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHASTANT-QUALLS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-349-0980
Mailing Address - Street 1:7651 TCHULAHOMA RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9227
Mailing Address - Country:US
Mailing Address - Phone:662-349-0980
Mailing Address - Fax:662-349-0980
Practice Address - Street 1:7651 TCHULAHOMA RD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9227
Practice Address - Country:US
Practice Address - Phone:662-349-0980
Practice Address - Fax:662-349-0980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care