Provider Demographics
NPI:1558187211
Name:ADAMS, OTHA ANDRAE
Entity type:Individual
Prefix:
First Name:OTHA
Middle Name:ANDRAE
Last Name:ADAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 COUNTY ROAD 3312
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:MS
Mailing Address - Zip Code:39330-9070
Mailing Address - Country:US
Mailing Address - Phone:601-527-2765
Mailing Address - Fax:
Practice Address - Street 1:9 COUNTY ROAD 3312
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:MS
Practice Address - Zip Code:39330-9070
Practice Address - Country:US
Practice Address - Phone:601-527-2765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-27
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle