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General NPI Number Information
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NPI Number | 1134635360
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Entity Type | Organization
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Legal Business Name | SOUTHERN REGIONAL CHIROPRACTIC AND REHABILITATION CENTER
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Dates
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Enumeration Date | 12/26/2017
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Last Update Date | 07/10/2018
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Provider Practice Location Address
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Address Line | 11505 CINEMA DR STE 7
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City | DIBERVILLE
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State | MS
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Zip | 39540
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Country | US
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Telephone | 228-365-0449
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Fax | 228-365-2314
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Provider Business Mailing Address
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Address Line | 11505 CINEMA DR STE 7
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City | DIBERVILLE
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State | MS
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Zip | 39540-9703
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Country | US
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Telephone | 228-365-0449
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Fax | 228-365-2314
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Authorized Official
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Title or Position | OWNER
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Name | MRS. SUSAN LEE KEENUM
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Credential |
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Telephone | 228-860-5027
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 901566
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 1221
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License Number State | MS
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