Healthcare Provider Details

I. General information

NPI: 1265803985
Provider Name (Legal Business Name): MISSISSIPPI PHS MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2015
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 MARKET ST
FLOWOOD MS
39232-3339
US

IV. Provider business mailing address

1509 DULLES DR
LAFAYETTE LA
70506-3718
US

V. Phone/Fax

Practice location:
  • Phone: 337-991-9276
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NICOLE HOWARD
Title or Position: CEO
Credential:
Phone: 337-991-9276