Healthcare Provider Details

I. General information

NPI: 1639338577
Provider Name (Legal Business Name): MAGNOLIA REGIONAL COMMUNITY CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 05/14/2021
Certification Date: 05/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 ALCOM DRIVE 109
CORINTH MS
38834-9302
US

IV. Provider business mailing address

401 ALCORN DR STE 2C
CORINTH MS
38834-9073
US

V. Phone/Fax

Practice location:
  • Phone: 662-293-1680
  • Fax: 662-293-1595
Mailing address:
  • Phone: 662-293-7618
  • Fax:

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. HOWARD D. NELSON
Title or Position: VP PHYSICAIN SERVICES
Credential:
Phone: 662-293-7618