Provider Demographics
NPI:1639395197
Name:AWAKENINGS, PA
Entity Type:Organization
Organization Name:AWAKENINGS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:STOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-831-9400
Mailing Address - Street 1:12231 ASHLEY DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2775
Mailing Address - Country:US
Mailing Address - Phone:228-831-9400
Mailing Address - Fax:228-831-9600
Practice Address - Street 1:12231 ASHLEY DR
Practice Address - Street 2:SUITE C
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2775
Practice Address - Country:US
Practice Address - Phone:228-831-9400
Practice Address - Fax:228-831-9600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13805251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSF21280Medicare UPIN