=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154571495
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MID-SOUTH FOOT & ANKLE CLINIC P C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2008
-----------------------------------------------------
Last Update Date | 09/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302 S RHODES ST
-----------------------------------------------------
City | WEST MEMPHIS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72301-4215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-732-3131
-----------------------------------------------------
Fax | 870-732-1301
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1118
-----------------------------------------------------
City | FORREST CITY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72336-1118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-732-3131
-----------------------------------------------------
Fax | 870-732-1301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. BHEKUMUZI M KHUMALO
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 870-732-3131
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 177
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------