Healthcare Provider Details

I. General information

NPI: 1225979826
Provider Name (Legal Business Name): STANFORD CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2026
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5192 MAIN ST
LUCEDALE MS
39452-6771
US

IV. Provider business mailing address

5192 MAIN ST
LUCEDALE MS
39452-6771
US

V. Phone/Fax

Practice location:
  • Phone: 601-947-0250
  • Fax:
Mailing address:
  • Phone: 601-947-0250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. CASEY STANFORD
Title or Position: OWNER/MD
Credential:
Phone: 601-947-0250