Facts
- Status
- A
- Credential
- D.C.
- Type
- Individual
- Enumeration date
- 2006-10-05
- Last updated
- 2010-10-29
Specialties
Licenses
- License MS
- 1032
Location
- Practice location
- 500 EAST 3RD ST.
- City
- FOREST MS
- Postal code
- 39074
- Phone
- 601-469-3030
Medicare
- PECOS
- A PECOS enrollment row matches this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.