Provider Demographics
NPI:1104466887
Name:SUPERIOR SOLES
Entity type:Organization
Organization Name:SUPERIOR SOLES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:MS
Authorized Official - First Name:LARONA
Authorized Official - Middle Name:RACHELLE
Authorized Official - Last Name:SEARCY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:601-503-0335
Mailing Address - Street 1:161 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-8751
Mailing Address - Country:US
Mailing Address - Phone:601-503-0335
Mailing Address - Fax:
Practice Address - Street 1:1888 MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110
Practice Address - Country:US
Practice Address - Phone:601-503-0335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care