1932476280 NPI number — PUCKETT MEDICAL CLINIC

Table of content: (NPI 1932476280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932476280 NPI number — PUCKETT MEDICAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUCKETT MEDICAL CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932476280
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 366
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUCKETT
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39151-0366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-824-9490
Provider Business Mailing Address Fax Number:
691-824-9533

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6455 HIGHWAY 18
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRANDON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39042-7536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-824-9490
Provider Business Practice Location Address Fax Number:
601-824-9533
Provider Enumeration Date:
11/30/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DEVELIN
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
601-824-9490

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  R633283 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)