Provider Demographics
NPI:1104006923
Name:PEACE CHILDREN'S CLINIC
Entity Type:Organization
Organization Name:PEACE CHILDREN'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOUISA
Authorized Official - Middle Name:E
Authorized Official - Last Name:LAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-924-2008
Mailing Address - Street 1:210 CLINTON PLZ
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-5126
Mailing Address - Country:US
Mailing Address - Phone:601-924-2008
Mailing Address - Fax:601-924-2022
Practice Address - Street 1:210 CLINTON PLZ
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-5126
Practice Address - Country:US
Practice Address - Phone:601-924-2008
Practice Address - Fax:601-924-2022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05705758Medicaid