Organization
IDEAL PROVIDER, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
NGOZI EDMUNDS (PRESIDENT)
(662) 342-7023
Entity
Organization
Contact information
Practice address
8869 CENTRE ST # 3, SOUTHAVEN, MS 38671-1725
(662) 342-7023
(662) 342-7089
Mailing address
8869 CENTRE ST, SOUTHAVEN, MS 38671-1725
(662) 342-7023
(662) 342-7089
Taxonomy
Speciality
Code
Description
License number
State
261QM0855X
Adolescent and Children Mental Health Clinic/Center
—
—
282E00000X
Long Term Care Hospital
—
—
385H00000X
Respite Care
Primary
—
—
Other
Enumeration date
05/13/2009
Last updated
05/13/2009
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