Organization
HEAVENLY PALACE ADULT CENTER, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. PATRICK JACKSON (PRESIDENT)
(662) 378-7262
Entity
Organization
Contact information
Practice address
1654 HIGHWAY 1 N, GREENVILLE, MS 38701-0000
(662) 378-7262
Mailing address
1654 HIGHWAY 1 N, GREENVILLE, MS 38703-1943
(662) 378-7262
Taxonomy
Speciality
Code
Description
License number
State
305R00000X
Preferred Provider Organization
Primary
07186736
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
07186736
—
MS
Enumeration date
02/26/2008
Last updated
02/26/2008
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