Provider Demographics
NPI:1023264934
Name:BORDERS-BLACKWELL MEDICAL & WELLNESS CORPORATION
Entity type:Organization
Organization Name:BORDERS-BLACKWELL MEDICAL & WELLNESS CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BORDERS-BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:662-843-8700
Mailing Address - Street 1:321 S SHARPE AVE
Mailing Address - Street 2:POST OFFICE BOX 1998
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732
Mailing Address - Country:US
Mailing Address - Phone:662-843-8700
Mailing Address - Fax:662-843-9100
Practice Address - Street 1:321 S SHARPE AVE
Practice Address - Street 2:POST OFFICE BOX 1998
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732
Practice Address - Country:US
Practice Address - Phone:662-843-8700
Practice Address - Fax:662-843-9100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20725261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07079055Medicaid
MS07079055Medicaid