Healthcare Provider Details

I. General information

NPI: 1265756951
Provider Name (Legal Business Name): ALL CHILDREN'S CLINIC,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2010
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 HALLS CV
SENATOBIA MS
38668-6620
US

IV. Provider business mailing address

103 HALLS CV
SENATOBIA MS
38668-6620
US

V. Phone/Fax

Practice location:
  • Phone: 662-562-9003
  • Fax: 662-562-4007
Mailing address:
  • Phone: 662-562-9003
  • Fax: 662-562-4007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMS14916
License Number StateMS

VIII. Authorized Official

Name: MRS. DIPIKA P VERMA
Title or Position: PRACTICE ADMINISTRATOR
Credential: MBA
Phone: 662-562-9003