Provider Demographics
NPI:1134370828
Name:HWY 63 MEDICAL AND CHIROPRACTIC CENTER, P.A.
Entity type:Organization
Organization Name:HWY 63 MEDICAL AND CHIROPRACTIC CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VANCE
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:WARDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:228-588-0188
Mailing Address - Street 1:PO BOX 901
Mailing Address - Street 2:
Mailing Address - City:HURLEY
Mailing Address - State:MS
Mailing Address - Zip Code:39555-0901
Mailing Address - Country:US
Mailing Address - Phone:228-588-0188
Mailing Address - Fax:228-588-9184
Practice Address - Street 1:19621 HWY 63
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39562
Practice Address - Country:US
Practice Address - Phone:228-588-0188
Practice Address - Fax:228-588-9184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-01
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X, 207Q00000X
MS987111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123522Medicaid
MS587618900COtherBLUE CROSS BLUE SHIELD
MS350000283Medicare PIN