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General NPI Number Information
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NPI Number | 1629279054
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Entity Type | Organization
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Legal Business Name | VICKSBURG CLINIC LLC
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Dates
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Enumeration Date | 05/31/2007
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Last Update Date | 02/14/2025
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Provider Practice Location Address
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Address Line | 107 FRONT ST STE 1200
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City | VIDALIA
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State | LA
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Zip | 71373-2834
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Country | US
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Telephone | 318-336-2220
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Fax | 318-336-6060
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Provider Business Mailing Address
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Address Line | 508 BROADWAY
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City | DELHI
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State | LA
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Zip | 71232-3002
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Country | US
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Telephone | 318-878-3737
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Fax |
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Authorized Official
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Title or Position | DIRECTOR PROVIDER ENROLLMENT
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Name | KRISTY MUSIC
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Credential |
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Telephone | 615-465-7377
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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