Healthcare Provider Details

I. General information

NPI: 1992409262
Provider Name (Legal Business Name): LUCEDALE FAMILY MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 05/10/2024
Certification Date: 05/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 WINTER ST STE D
LUCEDALE MS
39452-6078
US

IV. Provider business mailing address

6577 CREEL RD
THEODORE AL
36582-3857
US

V. Phone/Fax

Practice location:
  • Phone: 601-791-5012
  • Fax: 601-791-5013
Mailing address:
  • Phone: 251-725-8455
  • Fax: 251-445-3722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BRIDGOT PETERS
Title or Position: BILLING DIRECTOR
Credential:
Phone: 251-445-7618