=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548975154
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONLEE CLINIC HYDRATION AND SPA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2023
-----------------------------------------------------
Last Update Date | 01/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 ENTERPRISE DR
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38655-2946
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-638-3412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 901
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38655-0901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | ELIZABETH HANCOCK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-507-2769
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------