Provider Demographics
NPI:1669061032
Name:THE CRANIAL PROSTHESIS CENTER OF MISSISSIPPI LLC
Entity type:Organization
Organization Name:THE CRANIAL PROSTHESIS CENTER OF MISSISSIPPI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIERRA
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:769-237-0443
Mailing Address - Street 1:717 RICE RD STE G
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-3041
Mailing Address - Country:US
Mailing Address - Phone:601-790-7269
Mailing Address - Fax:601-590-8991
Practice Address - Street 1:717 RICE RD STE G
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-3041
Practice Address - Country:US
Practice Address - Phone:601-790-7269
Practice Address - Fax:601-590-8991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-11
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier