Healthcare Provider Details

I. General information

NPI: 1568040517
Provider Name (Legal Business Name): TALLAHATCHIE GENERAL HOSPITAL MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 03/31/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 HONEYSUCKLE DRIVE
CHARLESTON MS
38921
US

IV. Provider business mailing address

188 HONEYSUCKLE DRIVE
CHARLESTON MS
38921
US

V. Phone/Fax

Practice location:
  • Phone: 501-276-5459
  • Fax: 662-625-3024
Mailing address:
  • Phone: 501-276-5459
  • Fax: 662-625-3024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: DR. CATHERINE DANE MORING
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD RDN CDCES BCADM
Phone: 501-276-5459