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General NPI Number Information
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NPI Number | 1649479429
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Entity Type | Organization
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Legal Business Name | WESTRIDGE FAMILY CLINIC
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Dates
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Enumeration Date | 07/12/2007
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Last Update Date | 07/12/2007
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Provider Practice Location Address
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Address Line | 307 S 13TH AVE
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City | LAUREL
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State | MS
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Zip | 39440-4342
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Country | US
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Telephone | 601-649-7600
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Fax | 601-649-7628
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Provider Business Mailing Address
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Address Line | 307 S 13TH AVE
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City | LAUREL
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State | MS
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Zip | 39440-4342
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Country | US
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Telephone | 601-649-7600
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Fax | 601-649-7628
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Authorized Official
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Title or Position | GENERAL PARTNER
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Name | DR. CHRISTOPHER L MAULDIN
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Credential | M.D.
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Telephone | 601-649-7600
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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 | 12524
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License Number State | MS
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