Provider Demographics
NPI:1487988002
Name:VICKSBURG SPECIAL CARE CLINIC LLC
Entity type:Organization
Organization Name:VICKSBURG SPECIAL CARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:CHAD
Authorized Official - Last Name:BARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-529-9341
Mailing Address - Street 1:4077 PEMBERTON SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5580
Mailing Address - Country:US
Mailing Address - Phone:601-638-8600
Mailing Address - Fax:601-638-8661
Practice Address - Street 1:4077 PEMBERTON SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5580
Practice Address - Country:US
Practice Address - Phone:601-638-8600
Practice Address - Fax:601-638-8661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01483541Medicaid
MS01123325Medicaid
MS01123325Medicaid