Provider Demographics
NPI:1083339121
Name:MIZELL HEALTHCARE LLC
Entity Type:Organization
Organization Name:MIZELL HEALTHCARE LLC
Other - Org Name:SOUTHERN FAMILY URGENT CARE MOBILE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BABETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-802-3595
Mailing Address - Street 1:PO BOX 787
Mailing Address - Street 2:
Mailing Address - City:GRAND BAY
Mailing Address - State:AL
Mailing Address - Zip Code:36541-0787
Mailing Address - Country:US
Mailing Address - Phone:251-802-3595
Mailing Address - Fax:228-896-7174
Practice Address - Street 1:1962 SPRING HILL AVE
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36607-2304
Practice Address - Country:US
Practice Address - Phone:251-802-3595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-11
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL293842Medicaid