Provider Demographics
NPI:1255608816
Name:828 WALK IN CLINIC
Entity type:Organization
Organization Name:828 WALK IN CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:TSANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-273-4096
Mailing Address - Street 1:PO BOX 4594
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39535-4594
Mailing Address - Country:US
Mailing Address - Phone:228-273-4096
Mailing Address - Fax:866-809-7246
Practice Address - Street 1:12207 HWY 49
Practice Address - Street 2:SUITE 40
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503
Practice Address - Country:US
Practice Address - Phone:228-832-8872
Practice Address - Fax:866-809-7246
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAINSTOP SPINE CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR791344363L00000X
MS14282207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00114733Medicaid
MS04078379Medicaid
MS050000673Medicare PIN
MS04078379Medicaid
MS500001505Medicare PIN
MS00114733Medicaid