Healthcare Provider Details

I. General information

NPI: 1255608816
Provider Name (Legal Business Name): 828 WALK IN CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12207 HWY 49 SUITE 40
GULFPORT MS
39503
US

IV. Provider business mailing address

PO BOX 4594
BILOXI MS
39535-4594
US

V. Phone/Fax

Practice location:
  • Phone: 228-832-8872
  • Fax: 866-809-7246
Mailing address:
  • Phone: 228-273-4096
  • Fax: 866-809-7246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number14282
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR791344
License Number StateMS

VIII. Authorized Official

Name: STACEY M TSANG
Title or Position: GENERAL MANAGER
Credential:
Phone: 228-273-4096