Provider Demographics
NPI:1154735405
Name:THOMAS, MICHEAL (DIRECTOR)
Entity type:Individual
Prefix:MR
First Name:MICHEAL
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751-2131
Mailing Address - Country:US
Mailing Address - Phone:662-336-8087
Mailing Address - Fax:
Practice Address - Street 1:216 NORTH AVE
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:MS
Practice Address - Zip Code:38751-2131
Practice Address - Country:US
Practice Address - Phone:662-336-8087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-15
Last Update Date:2014-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS800064763347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle