Healthcare Provider Details

I. General information

NPI: 1659041663
Provider Name (Legal Business Name): CARE CLINIC FOR DRUG ADDICTION & MENTAL HEALTH IN NORTH MISSISSIPPI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 08/31/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8829 CENTRE ST STE 200
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 TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

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