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General NPI Number Information
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NPI Number | 1003620675
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Entity Type | Organization
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Legal Business Name | LEGACY FAMILY CARE CLINIC
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Dates
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Enumeration Date | 02/04/2025
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Last Update Date | 06/12/2025
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Provider Practice Location Address
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Address Line | 6798 U S HIGHWAY 98 STE 30
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City | HATTIESBURG
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State | MS
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Zip | 39402-7987
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Country | US
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Telephone | 601-596-9053
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Fax | 601-336-6615
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Provider Business Mailing Address
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Address Line | 6798 U S HIGHWAY 98 STE 30
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City | HATTIESBURG
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State | MS
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Zip | 39402-7987
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Country | US
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Telephone | 601-596-9053
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Fax | 601-336-6615
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Authorized Official
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Title or Position | OWNER
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Name | MRS. TARAH CHATHAM
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Credential | FNP-C
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Telephone | 601-596-9053
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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