Provider Demographics
NPI:1962913541
Name:PROLIFIC HEALTH & WELLNESS PA
Entity type:Organization
Organization Name:PROLIFIC HEALTH & WELLNESS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:MCCULLOUGH
Authorized Official - Last Name:SMASH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:769-257-0586
Mailing Address - Street 1:605 CHICKASAW DR N
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8680
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2675 RIVER RIDGE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5012
Practice Address - Country:US
Practice Address - Phone:769-257-0586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-23
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center