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General NPI Number Information
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NPI Number | 1972028843
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Entity Type | Organization
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Legal Business Name | DESOTO FAMILY CARE CLINIC, PLLC
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Dates
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Enumeration Date | 08/11/2017
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Last Update Date | 03/10/2023
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Provider Practice Location Address
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Address Line | 346 STATELINE RD W
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City | SOUTHAVEN
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State | MS
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Zip | 38671-1610
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Country | US
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Telephone | 662-510-5353
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Fax | 662-510-0409
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Provider Business Mailing Address
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Address Line | 5248 GARNER LN
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City | SOUTHAVEN
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State | MS
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Zip | 38672-6016
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Country | US
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Telephone | 662-510-5353
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Fax | 662-510-0409
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Authorized Official
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Title or Position | MSN
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Name | DIOSAN MANGUBAT POWELL
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Credential |
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Telephone | 662-510-5353
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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 | 901872
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License Number State | MS
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