# DIBERVILLE MEDICAL SPA

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

## Provider details

- **NPI number:** 1861766289
- **Authorized official:** RONNIE ALI DO (PRESIDENT)
- **Authorized official phone:** (228) 223-1927

## Contact information

- **Practice address:** 3661 SANGANI BLVD, SUITE C, DIBERVILLE, MS 39540-8706
- **Practice address phone:** (228) 223-1927
- **Mailing address:** PO BOX 1248, OCEAN SPRINGS, MS 39566-1248
- **Mailing address phone:** (228) 223-1927

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261Q00000X | Clinic/Center | — | NULL | Yes |

## Other

- **Enumeration date:** 03/02/2012
- **Last updated:** 03/02/2012