Healthcare Provider Details

I. General information

NPI: 1083084339
Provider Name (Legal Business Name): MAGNOLIA URGENT CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 05/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 ALCORN DR SUITE 109
CORINTH MS
38834-9302
US

IV. Provider business mailing address

703 ALCORN DR SUITE 109
CORINTH MS
38834-9302
US

V. Phone/Fax

Practice location:
  • Phone: 662-286-1499
  • Fax: 662-286-9041
Mailing address:
  • Phone: 662-286-1499
  • Fax: 662-286-9041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. RONNY HUMES
Title or Position: CEO
Credential:
Phone: 662-293-7664