Healthcare Provider Details

I. General information

NPI: 1629279054
Provider Name (Legal Business Name): VICKSBURG CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 FRONT ST STE 1200
VIDALIA LA
71373-2834
US

IV. Provider business mailing address

508 BROADWAY
DELHI LA
71232-3002
US

V. Phone/Fax

Practice location:
  • Phone: 318-336-2220
  • Fax: 318-336-6060
Mailing address:
  • Phone: 318-878-3737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KRISTY MUSIC
Title or Position: DIRECTOR PROVIDER ENROLLMENT
Credential:
Phone: 615-465-7377