Healthcare Provider Details

I. General information

NPI: 1699236497
Provider Name (Legal Business Name): WEBSTER FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24849 MS HIGHWAY 15
MATHISTON MS
39752-6900
US

IV. Provider business mailing address

PO BOX 190
MATHISTON MS
39752-0190
US

V. Phone/Fax

Practice location:
  • Phone: 662-634-3089
  • Fax: 662-634-3063
Mailing address:
  • Phone: 662-634-3089
  • Fax: 662-634-3063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. CHAD GARNETT
Title or Position: MANAGER
Credential:
Phone: 662-634-3089