Healthcare Provider Details

I. General information

NPI: 1164678520
Provider Name (Legal Business Name): LLOYD WAYNE ESTES PEDORTHIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2008
Last Update Date: 08/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WETUPKA WAY
HERNANDO MS
38632-4420
US

IV. Provider business mailing address

11301 WETUPKA WAY
HERNANDO MS
38632-4420
US

V. Phone/Fax

Practice location:
  • Phone: 662-560-7137
  • Fax: 662-449-4394
Mailing address:
  • Phone: 662-560-7137
  • Fax: 662-449-4394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: