Provider Demographics
NPI:1801471172
Name:SOUTHERN CHARM FAMILY HEALTHCARE
Entity type:Organization
Organization Name:SOUTHERN CHARM FAMILY HEALTHCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:601-829-6151
Mailing Address - Street 1:515 BELLE OAK PL
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-8111
Mailing Address - Country:US
Mailing Address - Phone:601-829-6151
Mailing Address - Fax:769-241-0044
Practice Address - Street 1:1201 HIGHWAY 49 S STE 46
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MS
Practice Address - Zip Code:39218-9438
Practice Address - Country:US
Practice Address - Phone:601-829-6151
Practice Address - Fax:769-241-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-17
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00936767Medicaid