| 121 Medical Place, Inc | |
|
820 Mangum Ave Mendenhall MS 39114-3025 | |
| (601) 906-1897 | |
| Not Available |
| Full Name | 121 Medical Place, Inc |
|---|---|
| Speciality | Clinic/Center |
| Location | 820 Mangum Ave, Mendenhall, Mississippi |
| Authorized Official Name and Position | Shelley Leach (PRESIDENT) |
| Authorized Official Contact | 6019061897 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| 121 Medical Place, Inc 820 Mangum Ave Mendenhall MS 39114-3025 Ph: () - | 121 Medical Place, Inc 820 Mangum Ave Mendenhall MS 39114-3025 Ph: (601) 906-1897 |
| NPI Number | 1588106553 |
|---|---|
| Provider Enumeration Date | 11/08/2016 |
| Last Update Date | 11/08/2016 |
| Medicare PECOS PAC ID | 9638454986 |
|---|---|
| Medicare Enrollment ID | O20170328002615 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1588106553 | NPI | - | NPPES |
| 00476391 | Medicaid | MS |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QC1500X | Clinic/center - Community Health | R863242 (Mississippi) | Primary |
| Provider Name | Shelley Smith Leach |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1760615595 PECOS PAC ID: 1557670940 Enrollment ID: I20151026002702 |
| Provider Name | Jessica M Tolar |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1326689662 PECOS PAC ID: 3173917259 Enrollment ID: I20220307001845 |
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