Healthcare Provider Details

I. General information

NPI: 1750051173
Provider Name (Legal Business Name): DESOTO WELLNESS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 09/16/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8829 CENTRE ST STE 100
SOUTHAVEN MS
38671-2610
US

IV. Provider business mailing address

222 SOUTHLAKES DR
GRENADA MS
38901-8499
US

V. Phone/Fax

Practice location:
  • Phone: 662-934-8671
  • Fax:
Mailing address:
  • Phone: 662-934-8671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. CEDRIC EDWARDS
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 662-934-8671