MEDICARE: EAST-END FAMILY MEDICAL CLINIC, LLC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1487118733
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST-END FAMILY MEDICAL CLINIC, LLC

Provider Business Mailing Address
First Line	:	1500 N BAYOU RD
Second Line	:
City	:	CLEVELAND
State	:	MS
Zip	:	38732-9723
Country	:	US
Telephone Number	:	662-721-8036
Fax Number	:

Provider Business Practice Location Address
First Line	:	140 NORTH ST
Second Line	:
City	:	CLEVELAND
State	:	MS
Zip	:	38732-2744
Country	:	US
Telephone Number	:	662-545-4674
Fax Number	:	662-545-4715

Authorized Official
Title or Position	:	FNP/ADMINISTRATOR
Name	:	MRS. CASSANDRA LATASHA SHEPARD
Credential	:	FNP-BC
Telephone Number	:	662-545-4674

Provider Enumeration Date	:	01/30/2019
Last Update Date	:	01/17/2024

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