Healthcare Provider Details

I. General information

NPI: 1215277652
Provider Name (Legal Business Name): KIDS KLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2013
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 COUNTRY CLUB RD
CARRIERE MS
39426-9037
US

IV. Provider business mailing address

200 COUNTRY CLUB RD
CARRIERE MS
39426-9037
US

V. Phone/Fax

Practice location:
  • Phone: 601-799-4777
  • Fax:
Mailing address:
  • Phone: 601-799-4777
  • Fax: 601-749-8818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number13678
License Number StateMS

VIII. Authorized Official

Name: DR. AHMAD HAIDAR
Title or Position: OWNER
Credential: MD
Phone: 601-799-4777