Healthcare Provider Details

I. General information

NPI: 1649479429
Provider Name (Legal Business Name): WESTRIDGE FAMILY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 S 13TH AVE
LAUREL MS
39440-4342
US

IV. Provider business mailing address

307 S 13TH AVE
LAUREL MS
39440-4342
US

V. Phone/Fax

Practice location:
  • Phone: 601-649-7600
  • Fax: 601-649-7628
Mailing address:
  • Phone: 601-649-7600
  • Fax: 601-649-7628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12524
License Number StateMS

VIII. Authorized Official

Name: DR. CHRISTOPHER L MAULDIN
Title or Position: GENERAL PARTNER
Credential: M.D.
Phone: 601-649-7600