Healthcare Provider Details

I. General information

NPI: 1134631641
Provider Name (Legal Business Name): MISSISSIPPI BELMONT CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2017
Last Update Date: 10/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 3RD ST PO BOX 190
BELMONT MS
38827-0190
US

IV. Provider business mailing address

PO BOX 628
BELMONT MS
38827-0628
US

V. Phone/Fax

Practice location:
  • Phone: 662-454-3401
  • Fax:
Mailing address:
  • Phone: 662-454-3401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DONALD R RATLIFF
Title or Position: PROVIDER
Credential: MD
Phone: 662-454-3401