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General NPI Number Information
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NPI Number | 1346476322
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Entity Type | Organization
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Legal Business Name | PEDIATRIC CARE CLINIC
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Dates
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Enumeration Date | 06/04/2009
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Last Update Date | 06/04/2009
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Provider Practice Location Address
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Address Line | 421 RIVER RD
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City | PICAYUNE
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State | MS
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Zip | 39466-3160
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Country | US
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Telephone | 985-726-2655
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Fax | 985-643-9808
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Provider Business Mailing Address
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Address Line | 421 RIVER RD
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City | PICAYUNE
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State | MS
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Zip | 39466-3160
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Country | US
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Telephone | 985-726-2655
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Fax | 985-643-9808
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Authorized Official
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Title or Position | OWNER
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Name | DR. ASHRAF TABATABAII
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Credential | MD
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Telephone | 985-726-2655
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 10074
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License Number State | MS
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