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General NPI Number Information
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NPI Number | 1598049264
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Entity Type | Organization
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Legal Business Name | DELTA CONCIERGE MEDICINE, INC.
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Dates
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Enumeration Date | 09/29/2011
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Last Update Date | 09/29/2011
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Provider Practice Location Address
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Address Line | 705 N STATE ST
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City | CLARKSDALE
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State | MS
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Zip | 38614-6519
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Country | US
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Telephone | 662-621-2192
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1930
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City | CLARKSDALE
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State | MS
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Zip | 38614-7930
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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 | CHIEF EXECUTIVE OFFICER
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Name | DR. KENNETH KELLOUGH
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Credential |
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Telephone | 662-621-2192
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 16776
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License Number State | MS
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