Provider Demographics
NPI:1972028843
Name:DESOTO FAMILY CARE CLINIC, PLLC
Entity Type:Organization
Organization Name:DESOTO FAMILY CARE CLINIC, PLLC
Other - Org Name:DESOTO FAMILY CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MSN
Authorized Official - Prefix:
Authorized Official - First Name:DIOSAN
Authorized Official - Middle Name:MANGUBAT
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-510-5353
Mailing Address - Street 1:5248 GARNER LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-6016
Mailing Address - Country:US
Mailing Address - Phone:662-510-5353
Mailing Address - Fax:662-510-0409
Practice Address - Street 1:346 STATELINE RD W
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-1610
Practice Address - Country:US
Practice Address - Phone:662-510-5353
Practice Address - Fax:662-510-0409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-11
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901872207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty