| NPI | 1861715534 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DAVID L MOAK Practice Administrator 601-354-4836 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 174400000X Specialist (Licence: MS 09 00008210) |
| Enumeration Date | 2010-03-09 |
| Last Update Date | 2011-08-19 |