Healthcare Provider Details

I. General information

NPI: 1003928672
Provider Name (Legal Business Name): BROOKHAVEN CHILDREN'S CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 HIGHWAY 51 N
BROOKHAVEN MS
39601-2337
US

IV. Provider business mailing address

624 HIGHWAY 51 N
BROOKHAVEN MS
39601-2337
US

V. Phone/Fax

Practice location:
  • Phone: 601-835-2100
  • Fax: 601-835-0451
Mailing address:
  • Phone: 601-835-2100
  • Fax: 601-835-0451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number11043
License Number StateMS

VIII. Authorized Official

Name: DR. CHARLES M HOLLAND
Title or Position: OWNER
Credential: M.D.
Phone: 601-835-2100