Healthcare Provider Details

I. General information

NPI: 1902233778
Provider Name (Legal Business Name): HEART HYPERTENSION CHOLESTEROL & DIABETES CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2013
Last Update Date: 10/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15444 DEDEAUX RD STE B
GULFPORT MS
39503-2637
US

IV. Provider business mailing address

15444 DEDEAUX RD STE B
GULFPORT MS
39503-2637
US

V. Phone/Fax

Practice location:
  • Phone: 228-832-9038
  • Fax: 228-832-9990
Mailing address:
  • Phone: 228-832-9038
  • Fax: 228-832-9990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVEN SMITH
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 502-244-9859