Healthcare Provider Details

I. General information

NPI: 1538110713
Provider Name (Legal Business Name): CENTER FOR DIGESTIVE HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 10/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

589 GARFIELD ST
TUPELO MS
38801-6301
US

IV. Provider business mailing address

PO BOX 3488
TUPELO MS
38803-3488
US

V. Phone/Fax

Practice location:
  • Phone: 662-680-5565
  • Fax: 662-680-5654
Mailing address:
  • Phone: 662-680-5565
  • Fax: 662-680-5654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number25C0001058
License Number StateMS

VIII. Authorized Official

Name: TERESA ELLIS
Title or Position: OFFICE MANAGER
Credential:
Phone: 662-680-5565