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General NPI Number Information
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NPI Number | 1497826044
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Entity Type | Organization
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Legal Business Name | CEDAR LAKE PEDIATRIC CLINIC PLLC
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Dates
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Enumeration Date | 11/13/2006
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Last Update Date | 07/12/2007
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Provider Practice Location Address
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Address Line | 1721 MEDICAL PARK DR STE 200
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City | BILOXI
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State | MS
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Zip | 39532-2105
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Country | US
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Telephone | 228-248-2572
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Fax | 228-396-0687
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Provider Business Mailing Address
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Address Line | PO BOX 8873
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City | BILOXI
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State | MS
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Zip | 39535-8873
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Country | US
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Telephone | 228-248-2572
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Fax | 228-396-0687
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Authorized Official
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Title or Position | OWNER
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Name | DR. LISA J HALLER
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Credential | MD
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Telephone | 228-248-2572
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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 |
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License Number State |
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