Provider Demographics
NPI:1063957751
Name:AUTOSPA-HEALTHY YOUTH CENTER
Entity type:Organization
Organization Name:AUTOSPA-HEALTHY YOUTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOSKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-209-1202
Mailing Address - Street 1:1202 DESOTO AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614
Mailing Address - Country:US
Mailing Address - Phone:662-209-1202
Mailing Address - Fax:662-483-1627
Practice Address - Street 1:1202 DESOTO AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614
Practice Address - Country:US
Practice Address - Phone:662-209-1202
Practice Address - Fax:662-483-1627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty