Provider Demographics
NPI:1972771806
Name:PICAYUNE FAMILY PRACTICE CLINIC, LLC
Entity type:Organization
Organization Name:PICAYUNE FAMILY PRACTICE CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:228-385-7715
Mailing Address - Street 1:PO BOX 6913
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-6913
Mailing Address - Country:US
Mailing Address - Phone:228-385-7715
Mailing Address - Fax:228-385-7719
Practice Address - Street 1:422 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-5544
Practice Address - Country:US
Practice Address - Phone:601-798-2151
Practice Address - Fax:601-798-2184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care