Healthcare Provider Details

I. General information

NPI: 1487601084
Provider Name (Legal Business Name): PICAYUNE CHIROPRACTIC CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 N CURRAN AVE SUITE E1
PICAYUNE MS
39466-4002
US

IV. Provider business mailing address

214 N CURRAN AVE SUITE E1
PICAYUNE MS
39466-4002
US

V. Phone/Fax

Practice location:
  • Phone: 601-889-1633
  • Fax: 604-889-1633
Mailing address:
  • Phone: 601-889-1633
  • Fax: 601-889-1633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1093
License Number StateMS

VIII. Authorized Official

Name: DR. RICCO VITO IMPASTATO
Title or Position: CHIROPRACTOR
Credential: D.C.
Phone: 601-889-1633