Healthcare Provider Details

I. General information

NPI: 1386868719
Provider Name (Legal Business Name): NETTLETON FAMILY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 WEST MAIN ST
NETTLETON MS
38858
US

IV. Provider business mailing address

123 MAIN ST N
AMORY MS
38821-3416
US

V. Phone/Fax

Practice location:
  • Phone: 662-963-3634
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRIS DEDEAUX
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 662-256-7112