Healthcare Provider Details

I. General information

NPI: 1255414173
Provider Name (Legal Business Name): FAMILY PRACTICE CLINIC OF WATER VALLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 SO MAIN ST
WATER VALLEY MS
38965
US

IV. Provider business mailing address

PO BOX 643
WATER VALLEY MS
38965
US

V. Phone/Fax

Practice location:
  • Phone: 662-473-4050
  • Fax: 662-473-4191
Mailing address:
  • Phone: 662-473-4050
  • Fax: 662-473-4191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18660
License Number StateMS

VIII. Authorized Official

Name: DRAGICA MILICEVIC
Title or Position: FAMILY PRACTICE
Credential: MD
Phone: 662-473-4050