Healthcare Provider Details

I. General information

NPI: 1942114368
Provider Name (Legal Business Name): DELTA KIDNEY ALLIANCE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 S COLORADO ST
GREENVILLE MS
38703-7219
US

IV. Provider business mailing address

1502 S COLORADO ST
GREENVILLE MS
38703-7219
US

V. Phone/Fax

Practice location:
  • Phone: 662-335-4105
  • Fax: 662-378-2879
Mailing address:
  • Phone: 662-335-4105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. LEATHE GREENLEE
Title or Position: MANAGER
Credential:
Phone: 662-335-4105