Provider Demographics
NPI:1699005983
Name:MALL SERVICES, LLC
Entity Type:Organization
Organization Name:MALL SERVICES, LLC
Other - Org Name:THE VILLAGE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:601-952-0673
Mailing Address - Street 1:350 W WOODROW WILSON AVE
Mailing Address - Street 2:SUITE 615
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-7681
Mailing Address - Country:US
Mailing Address - Phone:601-982-0673
Mailing Address - Fax:601-982-0459
Practice Address - Street 1:386 RAYMOND RD
Practice Address - Street 2:BUILDING 30
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3700
Practice Address - Country:US
Practice Address - Phone:601-982-0673
Practice Address - Fax:601-982-0459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122194Medicaid
MS00122254Medicaid
MS04135059Medicaid
MS1457562175Medicare PIN
MS512I080303Medicare PIN
MS00122194Medicaid
MS04135059Medicaid
MSH12744Medicare UPIN
MS00122254Medicaid