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1145 Highway 42 Petal MS 39465-9740 | |
(601) 545-8700 | |
(601) 450-2493 |
Full Name | |
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Speciality | Clinic/Center |
Location | 1145 Highway 42, Petal, Mississippi |
Authorized Official Name and Position | Kaye Ray (C E O) |
Authorized Official Contact | 6015458700 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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Po Box 1729 Hattiesburg MS 39403-1729 Ph: (601) 545-3700 | 1145 Highway 42 Petal MS 39465-9740 Ph: (601) 545-8700 |
NPI Number | 1003153073 |
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Provider Enumeration Date | 01/11/2013 |
Last Update Date | 09/06/2022 |
Medicare PECOS PAC ID | 2466342605 |
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Medicare Enrollment ID | O20130610000575 |
Identifier | Type | State | Issuer |
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1003153073 | NPI | - | NPPES |
Taxonomy | Type | License (State) | Status |
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261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (Mississippi) | Primary |