Provider Demographics
NPI:1972828259
Name:LAUREL CLINIC FOR WOMEN
Entity Type:Organization
Organization Name:LAUREL CLINIC FOR WOMEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLTON
Authorized Official - Middle Name:R
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-428-7221
Mailing Address - Street 1:115 S MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-4431
Mailing Address - Country:US
Mailing Address - Phone:601-428-7221
Mailing Address - Fax:601-428-7223
Practice Address - Street 1:115 S MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4431
Practice Address - Country:US
Practice Address - Phone:601-428-7221
Practice Address - Fax:601-428-7223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS03106174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSB30740Medicare UPIN