Healthcare Provider Details

I. General information

NPI: 1619346863
Provider Name (Legal Business Name): SOUTH CENTRAL CLINICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2015
Last Update Date: 01/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 JEFFERSON ST SUITE B
LAUREL MS
39440-4243
US

IV. Provider business mailing address

PO BOX 247
LAUREL MS
39441-0247
US

V. Phone/Fax

Practice location:
  • Phone: 601-649-6213
  • Fax: 601-649-6217
Mailing address:
  • Phone: 601-425-7550
  • Fax: 601-399-6281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES T CANIZARO
Title or Position: CFO/VP OF FINANCE
Credential:
Phone: 601-399-6139