Healthcare Provider Details

I. General information

NPI: 1629477526
Provider Name (Legal Business Name): BERRY ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2014
Last Update Date: 08/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

756 LUCKNEY RD
BRANDON MS
39042-8703
US

IV. Provider business mailing address

756 LUCKNEY RD
BRANDON MS
39042-8703
US

V. Phone/Fax

Practice location:
  • Phone: 601-824-3255
  • Fax: 601-944-9780
Mailing address:
  • Phone: 601-824-3255
  • Fax: 601-944-9780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT M BERRY
Title or Position: OWNER
Credential: MD
Phone: 601-824-3255