| Desoto Family Care Clinic, Pllc | |
|
346 Stateline Rd W Southaven MS 38671-1610 | |
| (662) 510-5353 | |
| (662) 510-0409 |
| Full Name | Desoto Family Care Clinic, Pllc |
|---|---|
| Speciality | Family Medicine |
| Location | 346 Stateline Rd W, Southaven, Mississippi |
| Authorized Official Name and Position | Diosan Mangubat Powell (MSN) |
| Authorized Official Contact | 6625105353 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Desoto Family Care Clinic, Pllc 5248 Garner Ln Southaven MS 38672-6016 Ph: (662) 510-5353 | Desoto Family Care Clinic, Pllc 346 Stateline Rd W Southaven MS 38671-1610 Ph: (662) 510-5353 |
| NPI Number | 1972028843 |
|---|---|
| Provider Enumeration Date | 08/11/2017 |
| Last Update Date | 03/10/2023 |
| Medicare PECOS PAC ID | 7719249978 |
|---|---|
| Medicare Enrollment ID | O20180328000476 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1972028843 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | 901872 (Mississippi) | Primary |
| Provider Name | Diosan Mangubat Powell |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1275086902 PECOS PAC ID: 5395033351 Enrollment ID: I20180328000562 |
| Provider Name | Thitiporn Whaley |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1295187789 PECOS PAC ID: 5395090559 Enrollment ID: I20230822004309 |
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