Provider Demographics
NPI:1427171107
Name:SANDRA GANT
Entity type:Organization
Organization Name:SANDRA GANT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:D
Authorized Official - Last Name:GANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-647-0093
Mailing Address - Street 1:8865 FIRST INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-1919
Mailing Address - Country:US
Mailing Address - Phone:662-342-8527
Mailing Address - Fax:662-280-3708
Practice Address - Street 1:8865 FIRST INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1919
Practice Address - Country:US
Practice Address - Phone:662-342-8527
Practice Address - Fax:662-280-3708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS068039932332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00045117Medicaid
MS0240690002Medicare ID - Type Unspecified