Healthcare Provider Details

I. General information

NPI: 1821927468
Provider Name (Legal Business Name): INTERVENE DIABETIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20735 HIGHWAY 12
LEXINGTON MS
39095-8266
US

IV. Provider business mailing address

PO BOX 61
FREMONT NC
27830-0061
US

V. Phone/Fax

Practice location:
  • Phone: 662-834-3432
  • Fax:
Mailing address:
  • Phone: 931-771-2521
  • Fax: 984-202-2422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MAURICE HAMPTON
Title or Position: AUTHORIZED OFFICIAL/OWNER
Credential:
Phone: 901-791-1711