Healthcare Provider Details

I. General information

NPI: 1578735791
Provider Name (Legal Business Name): ALWIN MAX JUCHHEIM III, DPM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2008
Last Update Date: 03/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 SUNSET DR SUITE P
GRENADA MS
38901-4086
US

IV. Provider business mailing address

1300 SUNSET DR SUITE P
GRENADA MS
38901-4086
US

V. Phone/Fax

Practice location:
  • Phone: 662-226-3333
  • Fax: 662-226-7722
Mailing address:
  • Phone: 662-226-3333
  • Fax: 662-226-7722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number80068
License Number StateMS

VIII. Authorized Official

Name: MRS. KATHY J LYON
Title or Position: OFFICE MANAGER
Credential:
Phone: 662-226-3333