Provider Demographics
NPI:1366629040
Name:LONG BEACH PASS MEDICAL
Entity type:Organization
Organization Name:LONG BEACH PASS MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:228-217-4321
Mailing Address - Street 1:4476 PIERCE RD
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-3404
Mailing Address - Country:US
Mailing Address - Phone:228-217-4321
Mailing Address - Fax:228-396-1115
Practice Address - Street 1:4476 PIERCE RD
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-3404
Practice Address - Country:US
Practice Address - Phone:228-217-4321
Practice Address - Fax:228-396-1115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies