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Organization
121 MEDICAL PLACE, INC
Active
Organization
121 MEDICAL PLACE, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SHELLEY LEACH FNP-C (PRESIDENT)
(601) 906-1897
Entity
Organization
Contact information
Practice address
820 MANGUM AVE, MENDENHALL, MS 39114-3025
(601) 906-1897
Mailing address
820 MANGUM AVE, MENDENHALL, MS 39114-3025
Taxonomy
Speciality
Code
Description
License number
State
261QC1500X
Community Health Clinic/Center
Primary
R863242
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00476391
—
MS
Enumeration date
11/08/2016
Last updated
08/06/2025
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