Healthcare Provider Details

I. General information

NPI: 1033366505
Provider Name (Legal Business Name): JACKSON COUNTY CHIROPRACTIC CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 08/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8820 HIGHWAY 613
MOSS POINT MS
39562-8102
US

IV. Provider business mailing address

PO BOX 656
ESCATAWPA MS
39552-0656
US

V. Phone/Fax

Practice location:
  • Phone: 228-475-0676
  • Fax:
Mailing address:
  • Phone: 228-475-0676
  • Fax: 228-475-0678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0429
License Number StateMS

VIII. Authorized Official

Name: DR. GARY LEE BRANHAM
Title or Position: OWNER
Credential:
Phone: 228-475-0676