Healthcare Provider Details

I. General information

NPI: 1649499740
Provider Name (Legal Business Name): LAKELAND SURGICAL CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 08/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR STE 1460
JACKSON MS
39216-4621
US

IV. Provider business mailing address

971 LAKELAND DR STE 1460
JACKSON MS
39216-4621
US

V. Phone/Fax

Practice location:
  • Phone: 601-982-3202
  • Fax: 601-982-3259
Mailing address:
  • Phone: 601-982-3202
  • Fax: 601-982-3259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. CATHY Y LOFTON
Title or Position: OFFICE MANAGER
Credential:
Phone: 601-982-3202