| Divinity Pediatric Clinic, Pllc | |
|
200 Riverwind Dr Ste 104 Pearl MS 39208-5652 | |
| (601) 345-4044 | |
| (601) 510-9334 |
| Full Name | Divinity Pediatric Clinic, Pllc |
|---|---|
| Speciality | Nurse Practitioner |
| Location | 200 Riverwind Dr Ste 104, Pearl, Mississippi |
| Authorized Official Name and Position | Rekita D. Mccoy (CEO) |
| Authorized Official Contact | 6013454044 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Divinity Pediatric Clinic, Pllc 463 Magnolia Pl Brandon MS 39042-8482 Ph: (601) 934-2603 | Divinity Pediatric Clinic, Pllc 200 Riverwind Dr Ste 104 Pearl MS 39208-5652 Ph: (601) 345-4044 |
| NPI Number | 1629741152 |
|---|---|
| Provider Enumeration Date | 07/29/2021 |
| Last Update Date | 09/03/2022 |
| Medicare PECOS PAC ID | 2062810047 |
|---|---|
| Medicare Enrollment ID | O20211005002232 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1629741152 | NPI | - | NPPES |
| 1629741152 | Medicaid | MS |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | (* (Not Available)) | Secondary |
| 363LP0200X | Nurse Practitioner - Pediatrics | (* (Not Available)) | Primary |
| Provider Name | Rekita Dechelle Mccoy |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1215437058 PECOS PAC ID: 3476815671 Enrollment ID: I20180328002258 |
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