=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962689042
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELTA FOOT CLINICS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2008
-----------------------------------------------------
Last Update Date | 01/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1814 MISSION 66
-----------------------------------------------------
City | VICKSBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39180-3710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-638-7520
-----------------------------------------------------
Fax | 601-638-7541
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1814 MISSION 66
-----------------------------------------------------
City | VICKSBURG
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39180-3710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-638-7520
-----------------------------------------------------
Fax | 601-638-7541
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. BRIAN EDWARD SHOCKLEY
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 601-638-7520
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP1100X
-----------------------------------------------------
Taxonomy Name | Podiatric Clinic/Center
-----------------------------------------------------
License Number | 80142
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------