Provider Demographics
NPI:1780723502
Name:PICAYUNE URGENT CARE CLINIC, LLC
Entity type:Organization
Organization Name:PICAYUNE URGENT CARE CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:601-798-2151
Mailing Address - Street 1:422 MEMORIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-5544
Mailing Address - Country:US
Mailing Address - Phone:601-798-2151
Mailing Address - Fax:601-798-2184
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:2007-02-06
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09921516Medicaid
MSC04522Medicare PIN