Healthcare Provider Details

I. General information

NPI: 1134635360
Provider Name (Legal Business Name): SOUTHERN REGIONAL CHIROPRACTIC AND REHABILITATION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2017
Last Update Date: 07/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11505 CINEMA DR STE 7
DIBERVILLE MS
39540
US

IV. Provider business mailing address

11505 CINEMA DR STE 7
DIBERVILLE MS
39540-9703
US

V. Phone/Fax

Practice location:
  • Phone: 228-365-0449
  • Fax: 228-365-2314
Mailing address:
  • Phone: 228-365-0449
  • Fax: 228-365-2314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1221
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number901566
License Number StateMS

VIII. Authorized Official

Name: MRS. SUSAN LEE KEENUM
Title or Position: OWNER
Credential:
Phone: 228-860-5027