Provider Demographics
NPI:1053977298
Name:CAL-WAL SOUTHERN, LLC
Entity type:Organization
Organization Name:CAL-WAL SOUTHERN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:CALVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-213-9783
Mailing Address - Street 1:2753 ASCOT PL
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-8304
Mailing Address - Country:US
Mailing Address - Phone:601-456-0447
Mailing Address - Fax:
Practice Address - Street 1:114 W WALKER ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-4755
Practice Address - Country:US
Practice Address - Phone:601-456-0447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care