Provider Demographics
NPI:1538546247
Name:MISSISSIPPI LACTATION SERVICES
Entity type:Organization
Organization Name:MISSISSIPPI LACTATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:AUSTIN
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-932-6455
Mailing Address - Street 1:PO BOX 321412
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-1412
Mailing Address - Country:US
Mailing Address - Phone:601-932-6455
Mailing Address - Fax:
Practice Address - Street 1:435 KATHERINE DR STE B
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9781
Practice Address - Country:US
Practice Address - Phone:601-932-6455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174N00000X
MS9307208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0014803Medicaid