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General NPI Number Information
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NPI Number | 1588106553
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Entity Type | Organization
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Legal Business Name | 121 MEDICAL PLACE, INC
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Dates
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Enumeration Date | 11/08/2016
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Last Update Date | 08/06/2025
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Provider Practice Location Address
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Address Line | 820 MANGUM AVE
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City | MENDENHALL
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State | MS
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Zip | 39114-3025
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Country | US
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Telephone | 601-906-1897
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Fax |
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Provider Business Mailing Address
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Address Line | 820 MANGUM AVE
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City | MENDENHALL
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State | MS
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Zip | 39114-3025
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | SHELLEY LEACH
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Credential | FNP-C
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Telephone | 601-906-1897
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number | R863242
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License Number State | MS
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