Healthcare Provider Details

I. General information

NPI: 1770857443
Provider Name (Legal Business Name): XCEPTIONAL HEALTH & WELLNESS, PLLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2012
Last Update Date: 02/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5779 GETWELL RD BLDG. D, SUITE 3
SOUTHAVEN MS
38672-6347
US

IV. Provider business mailing address

5779 GETWELL RD BLDG. D, SUITE 3
SOUTHAVEN MS
38672-6347
US

V. Phone/Fax

Practice location:
  • Phone: 662-510-6507
  • Fax: 662-510-6508
Mailing address:
  • Phone: 662-510-6507
  • Fax: 662-510-6508

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: MRS. TRACEY F PETRIDES
Title or Position: OWNER/MD
Credential: MD
Phone: 662-510-6507