Organization
LIVING WATERS COMMUNITY MEDICAL CENTER PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. LISA MARIE TILLMAN (OFFICE MANAGER)
(228) 586-2455
Entity
Organization
Contact information
Practice address
13472 VIDALIA RD, PASS CHRISTIAN, MS 39571-8300
(228) 586-2455
Mailing address
13472 VIDALIA RD, PASS CHRISTIAN, MS 39571-8300
(228) 586-2455
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
06960
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
09015234
—
MS
Enumeration date
12/12/2007
Last updated
12/12/2007
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