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General NPI Number Information
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NPI Number | 1023478435
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Entity Type | Organization
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Legal Business Name | LA MISS DIABETIC SHOES
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Dates
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Enumeration Date | 02/26/2016
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Last Update Date | 02/26/2016
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Provider Practice Location Address
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Address Line | 2200 HIGHWAY 61 N SUITE 3400
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City | VICKSBURG
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State | MS
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Zip | 39183-8246
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Country | US
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Telephone | 601-883-3342
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Fax | 601-856-5955
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Provider Business Mailing Address
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Address Line | 139 SOUTHERN RIDGE DR
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City | MADISON
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State | MS
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Zip | 39110-9484
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Country | US
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Telephone | 601-883-3342
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Fax | 601-856-5955
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | MRS. STEPHANIE F PHELAN
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Credential | DPM
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Telephone | 601-883-3342
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 80145
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License Number State | MS
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