Provider Demographics
NPI:1568670040
Name:AGAPE MEDICAL SERVICES
Entity Type:Organization
Organization Name:AGAPE MEDICAL SERVICES
Other - Org Name:AGAPE MEDICAL PRODUCTS AND SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-948-0009
Mailing Address - Street 1:1075 PECAN PARK CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-6914
Mailing Address - Country:US
Mailing Address - Phone:601-948-0009
Mailing Address - Fax:601-948-0079
Practice Address - Street 1:1075 PECAN PARK CIR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-6914
Practice Address - Country:US
Practice Address - Phone:601-948-0009
Practice Address - Fax:601-948-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05799111332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440338Medicaid
MS00440338Medicaid