Healthcare Provider Details

I. General information

NPI: 1477541670
Provider Name (Legal Business Name): FAMILY EAR NOSE & THROAT CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 03/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 PHYSICIANS LN STE 1
SOUTHAVEN MS
38671-6122
US

IV. Provider business mailing address

PO BOX 1017 60 PHYSICIAN LANE STE 1
SOUTHAVEN MS
38671-0011
US

V. Phone/Fax

Practice location:
  • Phone: 662-349-0707
  • Fax: 662-349-0708
Mailing address:
  • Phone: 662-349-0707
  • Fax: 662-349-0708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: TRACI L CATO
Title or Position: OFFICE MANAGER
Credential:
Phone: 662-349-0707