Vicksburg Clinic Llc
Legal Business Name
Vicksburg Clinic Llc
NPI Number
1659307791
NPI Type
Organization
Enumeration Date
06/23/2006
Specialties
(Taxonomies)Name
Code
207KA0200X
207RC0000X
207Q00000X
207R00000X
2084N0400X
363L00000X
207X00000X
208000000X
208800000X
Primary Taxonomy
No
No
No
No
No
No
No
No
No
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