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Organization
VICKSBURG CLINIC LLC
Active
Organization
VICKSBURG CLINIC LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DEBBIE T BREWER (DIRECTOR OF PROVIDER ENROLLMENT)
(877) 892-9813
Entity
Organization
Contact information
Practice address
10 CROTHERS DR, STE. 4, TALLULAH, LA 71282-5510
(318) 574-0056
Mailing address
10 CROTHERS DR, STE. 4, TALLULAH, LA 71282-5510
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
NULL
207Q00000X
Family Medicine Physician
Primary
—
—
207R00000X
Internal Medicine Physician
—
NULL
207R00000X
Internal Medicine Physician
—
—
208600000X
Surgery Physician
—
NULL
208600000X
Surgery Physician
—
—
208800000X
Urology Physician
—
NULL
208800000X
Urology Physician
—
—
208D00000X
General Practice Physician
—
NULL
208D00000X
General Practice Physician
—
—
Other
Enumeration date
05/22/2007
Last updated
10/01/2008
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