Healthcare Provider Details

I. General information

NPI: 1396379186
Provider Name (Legal Business Name): SOUTHERN FAMILY URGENT CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2020
Last Update Date: 02/14/2023
Certification Date: 02/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 HIGHWAY 49
GULFPORT MS
39503-2780
US

IV. Provider business mailing address

PO BOX 787
GRAND BAY AL
36541-0787
US

V. Phone/Fax

Practice location:
  • Phone: 228-999-9999
  • Fax:
Mailing address:
  • Phone: 228-206-6882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: AMANDA R MIZELL
Title or Position: OWNER/ NURSE PRACTITIONER
Credential: FNP
Phone: 228-896-7108