Healthcare Provider Details

I. General information

NPI: 1568459089
Provider Name (Legal Business Name): RIVER BEND MEDICAL CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2659 LAKELAND DR
FLOWOOD MS
39232-9516
US

IV. Provider business mailing address

2659 LAKELAND DR
FLOWOOD MS
39232-9516
US

V. Phone/Fax

Practice location:
  • Phone: 601-933-1199
  • Fax: 601-933-1116
Mailing address:
  • Phone: 601-933-1199
  • Fax: 601-933-1116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberNO LICENCE NUMBER
License Number StateMS

VIII. Authorized Official

Name: PAIGE E KEY
Title or Position: OWNER
Credential: CMA XRT
Phone: 601-933-1199