Provider Demographics
NPI:1255999835
Name:ECONOMIC STIMULUS ACT STUDENT LOAN REFUND 1200 DOLLARS
Entity type:Organization
Organization Name:ECONOMIC STIMULUS ACT STUDENT LOAN REFUND 1200 DOLLARS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SPECIALIST TECHNOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:CORNELIUS
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-253-0000
Mailing Address - Street 1:3301 N MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-4322
Mailing Address - Country:US
Mailing Address - Phone:650-253-0000
Mailing Address - Fax:
Practice Address - Street 1:5001 HARDY ST STE 8
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1308
Practice Address - Country:US
Practice Address - Phone:601-307-5339
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EPIC SYSTEMS CORPORATION APPLIED INFORMATICS PHYSICIAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QG0250XAmbulatory Health Care FacilitiesClinic/CenterGenetics
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
No293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS587539997Medicaid