Healthcare Provider Details

I. General information

NPI: 1760526990
Provider Name (Legal Business Name): HOLBROOK FAMILY MEDICAL PRACTICE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 04/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 OAK ST
MENDENHALL MS
39114-3650
US

IV. Provider business mailing address

102 OAK ST
MENDENHALL MS
39114-3650
US

V. Phone/Fax

Practice location:
  • Phone: 601-847-3712
  • Fax:
Mailing address:
  • Phone: 601-847-3712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number14412
License Number StateMS

VIII. Authorized Official

Name: CHIP D HOLBROOK
Title or Position: OWNER
Credential: MD
Phone: 601-847-3712