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General NPI Number Information
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NPI Number | 1902088453
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Entity Type | Organization
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Legal Business Name | CANTON FAMILY CLINIC INC.
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Dates
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Enumeration Date | 11/27/2007
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Last Update Date | 03/03/2010
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Provider Practice Location Address
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Address Line | 120 E ACADEMY ST
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City | CANTON
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State | MS
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Zip | 39046-4502
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Country | US
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Telephone | 601-859-2611
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Fax |
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Provider Business Mailing Address
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Address Line | 120 E ACADEMY ST
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City | CANTON
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State | MS
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Zip | 39046-4502
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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 | CLINIC ADMINISTRATOR
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Name | MR. JERRY LOUSTEAU
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Credential |
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Telephone | 601-859-2611
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 09015552
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License Number State | MS
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