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General NPI Number Information
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NPI Number | 1023228632
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Entity Type | Organization
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Legal Business Name | MAGNOLIA FAMILY MEDICAL CLINIC
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Dates
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Enumeration Date | 05/23/2007
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Last Update Date | 12/31/2007
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Provider Practice Location Address
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Address Line | 1660 S COLORADO ST
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City | GREENVILLE
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State | MS
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Zip | 38703-7216
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Country | US
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Telephone | 662-332-2077
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Fax | 662-332-0790
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Provider Business Mailing Address
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Address Line | 1660 S COLORADO ST
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City | GREENVILLE
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State | MS
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Zip | 38703-7216
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Country | US
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Telephone | 662-332-2077
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Fax | 662-332-0790
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Authorized Official
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Title or Position | OWNER
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Name | JOHN B KAYOMA
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Credential | MD
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Telephone | 662-332-2077
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 17503
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License Number State | MS
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