Provider Demographics
NPI:1992409262
Name:LUCEDALE FAMILY MEDICAL CLINIC
Entity type:Organization
Organization Name:LUCEDALE FAMILY MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGOT
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-445-7618
Mailing Address - Street 1:6577 CREEL RD
Mailing Address - Street 2:
Mailing Address - City:THEODORE
Mailing Address - State:AL
Mailing Address - Zip Code:36582-3857
Mailing Address - Country:US
Mailing Address - Phone:251-725-8455
Mailing Address - Fax:251-445-3722
Practice Address - Street 1:223 WINTER ST STE D
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-6078
Practice Address - Country:US
Practice Address - Phone:601-791-5012
Practice Address - Fax:601-791-5013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-29
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty