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General NPI Number Information
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NPI Number | 1922171826
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Entity Type | Organization
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Legal Business Name | BROOKSVILLE MEDICAL CLINIC INC
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Dates
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Enumeration Date | 11/16/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 139 N. OLIVER ST.
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City | BROOKSVILLE
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State | MS
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Zip | 39739-0348
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Country | US
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Telephone | 662-738-4424
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Fax | 662-738-4615
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Provider Business Mailing Address
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Address Line | PO BOX 348 139 N. OLIVER ST.
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City | BROOKSVILLE
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State | MS
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Zip | 39739-0348
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Country | US
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Telephone | 662-738-4424
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Fax | 662-738-4615
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. ERNEST ROY STUART JR.
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Credential |
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Telephone | 662-738-4424
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number | 253912
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License Number State | MS
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