Organization
MALL SERVICES, LLC
Active
Other names
THE VILLAGE CLINIC
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. CHRISTAL ROGERS LPN (CLINIC MANAGER)
(601) 952-0673
Entity
Organization
Contact information
Practice address
386 RAYMOND RD, BUILDING 30, JACKSON, MS 39204-3700
(601) 982-0673
(601) 982-0459
Mailing address
350 W WOODROW WILSON AVE, SUITE 615, JACKSON, MS 39213-7681
(601) 982-0673
(601) 982-0459
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00122194
—
MS
05
—
00122254
—
MS
05
—
04135059
—
MS
Enumeration date
01/08/2010
Last updated
01/08/2010
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