Healthcare Provider Details

I. General information

NPI: 1922032028
Provider Name (Legal Business Name): KENNETH FARRISH DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 HIGHWAY 80 W
CLINTON MS
39056-4103
US

IV. Provider business mailing address

705 HIGHWAY 80 W
CLINTON MS
39056-4103
US

V. Phone/Fax

Practice location:
  • Phone: 601-587-1367
  • Fax: 601-373-2879
Mailing address:
  • Phone: 601-587-1367
  • Fax: 601-373-2879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number80104
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: