Healthcare Provider Details

I. General information

NPI: 1962689042
Provider Name (Legal Business Name): DELTA FOOT CLINICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2008
Last Update Date: 01/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 MISSION 66
VICKSBURG MS
39180-3710
US

IV. Provider business mailing address

1814 MISSION 66
VICKSBURG MS
39180-3710
US

V. Phone/Fax

Practice location:
  • Phone: 601-638-7520
  • Fax: 601-638-7541
Mailing address:
  • Phone: 601-638-7520
  • Fax: 601-638-7541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number80142
License Number StateMS

VIII. Authorized Official

Name: DR. BRIAN EDWARD SHOCKLEY
Title or Position: PRESIDENT/OWNER
Credential: DPM
Phone: 601-638-7520