# 121 MEDICAL PLACE, INC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1588106553
- **Authorized official:** SHELLEY LEACH FNP-C (PRESIDENT)
- **Authorized official phone:** (601) 906-1897

## Contact information

- **Practice address:** 820 MANGUM AVE, MENDENHALL, MS 39114-3025
- **Practice address phone:** (601) 906-1897
- **Mailing address:** 820 MANGUM AVE, MENDENHALL, MS 39114-3025

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QC1500X | Community Health Clinic/Center | R863242 | MS | Yes |

## Other

- **Enumeration date:** 11/08/2016
- **Last updated:** 08/06/2025

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 00476391 | — | MS |