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General NPI Number Information
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NPI Number | 1649304122
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Entity Type | Organization
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Legal Business Name | DESOTO PHYSICIANS & SURGEONS CLINIC
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Dates
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Enumeration Date | 03/15/2007
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Last Update Date | 08/19/2008
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Provider Practice Location Address
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Address Line | 119 JEFFERSON ST
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City | MANSFIELD
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State | LA
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Zip | 71052-2601
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Country | US
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Telephone | 318-872-5810
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Fax | 318-872-2763
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Provider Business Mailing Address
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Address Line | 119 JEFFERSON ST PO BOX 739
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City | MANSFIELD
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State | LA
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Zip | 71052-2601
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Country | US
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Telephone | 318-872-5810
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Fax | 318-872-2763
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Authorized Official
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Title or Position | DIRECTOR OF CLINICS PHYS SRCS
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Name | MRS. TAMMY L KENNEDY
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Credential |
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Telephone | 318-872-4610
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 025688
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License Number State | LA
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