Provider Demographics
NPI:1801928700
Name:WARDEN, VANCE RAY I (DC)
Entity type:Individual
Prefix:MR
First Name:VANCE
Middle Name:RAY
Last Name:WARDEN
Suffix:I
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSF0113056363LF0000X
MS0987111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS350000283OtherPTAN
MS00123522Medicaid