Healthcare Provider Details

I. General information

NPI: 1003191867
Provider Name (Legal Business Name): GLUCKSTADT SPECIAL CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 10/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 HIGHWAY 51 STE M
MADISON MS
39110-5020
US

IV. Provider business mailing address

1716 HIGHWAY 51 STE M
MADISON MS
39110-5020
US

V. Phone/Fax

Practice location:
  • Phone: 601-707-5621
  • Fax: 601-707-9052
Mailing address:
  • Phone: 601-707-5621
  • Fax: 601-707-9052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KAREN M CONNER
Title or Position: DIRECTOR OF CLIENT SOLUTIONS
Credential: CPC
Phone: 318-255-7591