Provider Demographics
NPI:1881476364
Name:KING'S DAUGHTERS MEDICAL CENTER
Entity type:Organization
Organization Name:KING'S DAUGHTERS MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS DEVELOPMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:RICCERI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-835-9135
Mailing Address - Street 1:510 HIGHWAY 51 N STE B
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 HIGHWAY 51 N STE B
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2335
Practice Address - Country:US
Practice Address - Phone:601-833-6111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KING'S DAUGHTERS MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-10-18
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies