Healthcare Provider Details

I. General information

NPI: 1487852018
Provider Name (Legal Business Name): MISSION PRIMARY CARE CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 MISSION 66
VICKSBURG MS
39180-3711
US

IV. Provider business mailing address

1901 MISSION 66
VICKSBURG MS
39180-3711
US

V. Phone/Fax

Practice location:
  • Phone: 601-636-0097
  • Fax: 601-629-9969
Mailing address:
  • Phone: 601-636-0097
  • Fax: 601-629-9969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR829001
License Number StateMS

VIII. Authorized Official

Name: BILL FULCHER
Title or Position: ADM
Credential:
Phone: 601-636-0097