Provider Demographics
NPI:1174494975
Name:VICKSBURG CLINIC LLC
Entity type:Organization
Organization Name:VICKSBURG CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PROVIDER ENROLLMENT / AO
Authorized Official - Prefix:
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSIC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7377
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:615-465-7429
Mailing Address - Fax:615-628-6877
Practice Address - Street 1:3317 PEMBERTON SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5578
Practice Address - Country:US
Practice Address - Phone:601-636-1173
Practice Address - Fax:601-630-9674
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VICKSBURG CLINIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-09-15
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health