Healthcare Provider Details

I. General information

NPI: 1962634170
Provider Name (Legal Business Name): MAL S RIDDELL, D.O. CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 01/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 SUNSET DR SUITE B
GRENADA MS
38901-4086
US

IV. Provider business mailing address

1300 SUNSET DR SUITE B
GRENADA MS
38901-4086
US

V. Phone/Fax

Practice location:
  • Phone: 662-226-6430
  • Fax: 662-226-0018
Mailing address:
  • Phone: 662-226-6430
  • Fax: 662-226-0018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number08590
License Number StateMS

VIII. Authorized Official

Name: DR. MAL S RIDDELL III
Title or Position: OWNER
Credential: D.O.
Phone: 662-226-6430