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General NPI Number Information
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NPI Number | 1063865343
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Entity Type | Organization
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Legal Business Name | WJL PODIATRY CLINIC LLC
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Dates
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Enumeration Date | 07/21/2016
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Last Update Date | 03/28/2017
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Provider Practice Location Address
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Address Line | 953 NORTH ST
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City | JACKSON
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State | MS
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Zip | 39202-2615
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Country | US
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Telephone | 601-355-0026
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Fax | 601-355-0069
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Provider Business Mailing Address
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Address Line | 953 NORTH ST
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City | JACKSON
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State | MS
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Zip | 39202-2615
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Country | US
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Telephone | 601-355-0026
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Fax |
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Authorized Official
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Title or Position | DOCTOR
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Name | WILLIE LEWIS
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Credential | DPM
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Telephone | 601-355-0026
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP1100X
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Taxonomy Name | Podiatric Clinic/Center
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License Number | 80062
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License Number State | MS
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