1952163206 NPI number — PEDIATRIC & ADOLESCENT CLINIC LLC

Table of content: (NPI 1952163206)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952163206 NPI number — PEDIATRIC & ADOLESCENT CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC & ADOLESCENT CLINIC LLC
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:
1952163206
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
308 HIGHLAND BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NATCHEZ
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39120-4611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-442-7676
Provider Business Mailing Address Fax Number:
601-442-9590

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 N MARTIN LUTHER KING JR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NATCHEZ
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39120-3356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-442-7676
Provider Business Practice Location Address Fax Number:
601-442-9590
Provider Enumeration Date:
01/23/2024

Additional Information

Authorized Official

Authorized Official Last Name:
TIMM
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
601-442-7676

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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