1720789944 NPI number — NORTH MISSISSIPPI CLINICS LLC

Table of content: (NPI 1720789944)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720789944 NPI number — NORTH MISSISSIPPI CLINICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH MISSISSIPPI CLINICS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720789944
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
499 GLOSTER CREEK VLG STE A2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUPELO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38801-4749
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-620-6800
Provider Business Mailing Address Fax Number:
662-620-6950

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
616 ALCORN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORINTH
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38834-9393
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-331-1973
Provider Business Practice Location Address Fax Number:
662-331-1974
Provider Enumeration Date:
03/14/2023

Additional Information

Authorized Official

Authorized Official Last Name:
CHISHOLM
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
662-620-6800

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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