1790703296 NPI number — DIVERSIFIED INFUSIONCARE SOLUTIONS, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790703296 NPI number — DIVERSIFIED INFUSIONCARE SOLUTIONS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVERSIFIED INFUSIONCARE SOLUTIONS, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DIVERSIFIED INFUSIONCARE SOLUTIONS VITAL CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790703296
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5047
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39302-5047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-447-4095
Provider Business Mailing Address Fax Number:
601-482-7490

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
823 HIGHWAY 12 W
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
STARKVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39759-3593
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-320-9696
Provider Business Practice Location Address Fax Number:
662-320-9616
Provider Enumeration Date:
07/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAMILTON
Authorized Official First Name:
STAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
662-320-9696

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  04633/02.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00440638 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00330522 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com