Organization

Vicksburg Clinic Llc

Legal Business Name

Vicksburg Clinic Llc

NPI Number

1659307791

NPI Type

Organization

Enumeration Date

06/23/2006

Specialties

(Taxonomies)

Contact
Information

Purpose

Mailing
Location

Address

1115 N FRONTAGE RD
1115 N FRONTAGE RD

City

Vicksburg
Vicksburg

State

MS
MS

Postal Code

39180-5102
39180-5102

Country

US
US

Telephone Number

(601) 634-8790
(601) 634-8790

Authorized Official

Name

Debbie Brewer

Title or Position

DIRECTOR OF PROVIDER ENROLLMENT

Telephone Number

(877) 892-9813

Identifiers

Identifier

09015545
09015549
09015546
09015547
1111716
00720204

Identifier State

MS
MS
MS
MS
LA
MS

Identifier Issuer

Unknown
Unknown
Unknown
Unknown
Unknown
Unknown

Provider data last refreshed from NPPES NPI registry on 11/19/2024

Data last updated by provider on 11/25/2008

Provider Address