Provider Demographics
NPI:1619355203
Name:VICKSBURG CLINIC LLC
Entity type:Organization
Organization Name:VICKSBURG CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR PHYSICAN BUSINESS
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7587
Mailing Address - Street 1:4000 MERIDIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-6325
Mailing Address - Country:US
Mailing Address - Phone:615-465-7000
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5187
Practice Address - Country:US
Practice Address - Phone:601-883-3360
Practice Address - Fax:601-883-3364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-14
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health