Healthcare Provider Details

I. General information

NPI: 1619433943
Provider Name (Legal Business Name): LIVE OAKS ADDICTION PROFESSIONALS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5699 GETWELL RD STE 1
SOUTHAVEN MS
38672-7312
US

IV. Provider business mailing address

201 METHODIST BLVD STE 100
HATTIESBURG MS
39402-1267
US

V. Phone/Fax

Practice location:
  • Phone: 662-510-8400
  • Fax: 662-510-8500
Mailing address:
  • Phone: 601-296-3151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY D. CARR
Title or Position: SOLE MEMBER
Credential: MD
Phone: 662-510-8400