Healthcare Provider Details

I. General information

NPI: 1396811527
Provider Name (Legal Business Name): CLINTON FAMILY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309A MORRISON DR
CLINTON MS
39056-5239
US

IV. Provider business mailing address

309A MORRISON DR
CLINTON MS
39056-5239
US

V. Phone/Fax

Practice location:
  • Phone: 601-924-1877
  • Fax: 601-924-1871
Mailing address:
  • Phone: 601-924-1877
  • Fax: 601-924-1871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number09202
License Number StateMS

VIII. Authorized Official

Name: DR. DAVID BRICE WHEAT
Title or Position: PROPRIETOR
Credential: MD
Phone: 601-924-1877