Provider Demographics
NPI:1891975603
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:601-713-3900
Mailing Address - Street 1:514H E WOODROW WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4538
Mailing Address - Country:US
Mailing Address - Phone:601-713-3900
Mailing Address - Fax:601-713-3970
Practice Address - Street 1:514H E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4538
Practice Address - Country:US
Practice Address - Phone:601-713-3900
Practice Address - Fax:601-713-3970
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 Licenses
StateLicense IDTaxonomies
MS14149261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02305351Medicaid