Healthcare Provider Details

I. General information

NPI: 1699952606
Provider Name (Legal Business Name): WATERS FAMILY HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 MILL ST
BALDWYN MS
38824
US

IV. Provider business mailing address

305 MILL ST
BALDWYN MS
38824
US

V. Phone/Fax

Practice location:
  • Phone: 662-365-3253
  • Fax: 662-365-3484
Mailing address:
  • Phone: 662-365-3253
  • Fax: 662-365-3484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR574929
License Number StateMS

VIII. Authorized Official

Name: MRS. TAMMIE C WATERS
Title or Position: OWNER
Credential: CFNP
Phone: 662-365-3253