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General NPI Number Information
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NPI Number | 1013142017
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Entity Type | Organization
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Legal Business Name | NESHOBA FOOT AND ANKLE CLINIC
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Dates
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Enumeration Date | 05/19/2009
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Last Update Date | 05/19/2009
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Provider Practice Location Address
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Address Line | 1003 HOLLAND AVE SUITE 102
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City | PHILADELPHIA
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State | MS
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Zip | 39350-2180
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Country | US
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Telephone | 601-663-1423
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Fax | 601-663-1474
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Provider Business Mailing Address
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Address Line | 1003 HOLLAND AVE SUITE 102
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City | PHILADELPHIA
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State | MS
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Zip | 39350-2180
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Country | US
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Telephone | 601-663-1423
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Fax | 601-663-1474
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Authorized Official
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Title or Position | CBO MANAGER
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Name | MRS. STEPHANIE BUTLER
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Credential |
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Telephone | 601-663-1423
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 80193
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License Number State | MS
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