Provider Demographics
NPI:1245904150
Name:ACOUSTIC WAVE TREATMENT CENTER OF MS LLC
Entity type:Organization
Organization Name:ACOUSTIC WAVE TREATMENT CENTER OF MS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-944-5585
Mailing Address - Street 1:230 TRACE COLONY PARK DR STE 1
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-8851
Mailing Address - Country:US
Mailing Address - Phone:601-944-5585
Mailing Address - Fax:
Practice Address - Street 1:230 TRACE COLONY PARK DR STE 1
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-8851
Practice Address - Country:US
Practice Address - Phone:601-944-5585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-04
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center