MEDICARE: LEAKE MEMORIAL MEDICAL CLINIC WALNUT GROVE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	282NR1301X	Rural Acute Care Hospital

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053576819
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEAKE MEMORIAL MEDICAL CLINIC WALNUT GROVE

Provider Business Mailing Address
First Line	:	PO BOX 367
Second Line	:
City	:	WALNUT GROVE
State	:	MS
Zip	:	39189-0367
Country	:	US
Telephone Number	:	601-267-1400
Fax Number	:	601-253-9464

Provider Business Practice Location Address
First Line	:	110 PARK ST
Second Line	:
City	:	WALNUT GROVE
State	:	MS
Zip	:	39189-6526
Country	:	US
Telephone Number	:	601-267-1400
Fax Number	:	601-253-9464

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KRISTI ESTEP
Credential	:
Telephone Number	:	601-267-1400

Provider Enumeration Date	:	07/22/2008
Last Update Date	:	07/22/2008

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Directions to “LEAKE MEMORIAL MEDICAL CLINIC WALNUT GROVE ” Practice Location

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