Provider Demographics
NPI:1316736432
Name:INTERVENTIONAL DIABETES CENTER LLC 2
Entity type:Organization
Organization Name:INTERVENTIONAL DIABETES CENTER LLC 2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAURICE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMPTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-791-1711
Mailing Address - Street 1:211 E 2ND ST FL 1
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-4302
Mailing Address - Country:US
Mailing Address - Phone:901-791-1711
Mailing Address - Fax:
Practice Address - Street 1:211 E 2ND ST FL 1
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-4302
Practice Address - Country:US
Practice Address - Phone:901-791-1711
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty