MEDICARE: JACKSON COUNTY CHIROPRACTIC CLINIC PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	0429	MS

General Provider Information

NPI Number	:	1033366505
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON COUNTY CHIROPRACTIC CLINIC PA

Provider Business Mailing Address
First Line	:	PO BOX 656
Second Line	:
City	:	ESCATAWPA
State	:	MS
Zip	:	39552-0656
Country	:	US
Telephone Number	:	228-475-0676
Fax Number	:	228-475-0678

Provider Business Practice Location Address
First Line	:	8820 HIGHWAY 613
Second Line	:
City	:	MOSS POINT
State	:	MS
Zip	:	39562-8102
Country	:	US
Telephone Number	:	228-475-0676
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GARY LEE BRANHAM
Credential	:
Telephone Number	:	228-475-0676

Provider Enumeration Date	:	08/26/2008
Last Update Date	:	08/26/2008

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