| Vicksburg Special Care Clinic Llc | |
|
4077 Pemberton Square Blvd Vicksburg MS 39180-5580 | |
| (601) 638-8600 | |
| (601) 638-8661 |
| Full Name | Vicksburg Special Care Clinic Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 4077 Pemberton Square Blvd, Vicksburg, Mississippi |
| Authorized Official Name and Position | Mitchell Chad Barrett (OWNER/MEMBER) |
| Authorized Official Contact | 6015299341 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Vicksburg Special Care Clinic Llc 4077 Pemberton Square Blvd Vicksburg MS 39180-5580 Ph: (601) 638-8600 | Vicksburg Special Care Clinic Llc 4077 Pemberton Square Blvd Vicksburg MS 39180-5580 Ph: (601) 638-8600 |
| NPI Number | 1487988002 |
|---|---|
| Provider Enumeration Date | 09/29/2009 |
| Last Update Date | 10/29/2014 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1487988002 | NPI | - | NPPES |
| 01483541 | Medicaid | MS | |
| 01123325 | Medicaid | MS |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
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