Healthcare Provider Details

I. General information

NPI: 1134558331
Provider Name (Legal Business Name): SOUTH CENTRAL CLINICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2013
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 MATTHEW DR STE 8
WAYNESBORO MS
39367-2553
US

IV. Provider business mailing address

PO BOX 247
LAUREL MS
39441-0247
US

V. Phone/Fax

Practice location:
  • Phone: 601-671-3618
  • Fax: 601-671-3728
Mailing address:
  • Phone: 601-425-7550
  • Fax: 601-399-6281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES T CANIZARO
Title or Position: VP OF FINANCE/CFO
Credential:
Phone: 601-399-6139