Healthcare Provider Details

I. General information

NPI: 1578564712
Provider Name (Legal Business Name): PICAYUNE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 GOODYEAR BLVD
PICAYUNE MS
39466-3221
US

IV. Provider business mailing address

801 GOODYEAR BLVD
PICAYUNE MS
39466-3221
US

V. Phone/Fax

Practice location:
  • Phone: 601-798-4711
  • Fax: 601-749-3187
Mailing address:
  • Phone: 601-798-4711
  • Fax: 601-749-3187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License Number12086
License Number StateMS

VIII. Authorized Official

Name: STEVE GRIMM
Title or Position: CEO
Credential:
Phone: 601-798-4711