Provider Demographics
NPI:1679863138
Name:DIABETES MANAGEMENT CENTERS OF MISSISSIPPI, LLC
Entity Type:Organization
Organization Name:DIABETES MANAGEMENT CENTERS OF MISSISSIPPI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHIP
Authorized Official - Middle Name:
Authorized Official - Last Name:SLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-500-5367
Mailing Address - Street 1:3500 LAKELAND DR
Mailing Address - Street 2:SUITE 515
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-3017
Mailing Address - Country:US
Mailing Address - Phone:601-500-5367
Mailing Address - Fax:601-500-5370
Practice Address - Street 1:3500 LAKELAND DR
Practice Address - Street 2:SUITE 515
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-3017
Practice Address - Country:US
Practice Address - Phone:601-500-5367
Practice Address - Fax:601-500-5370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies