Healthcare Provider Details

I. General information

NPI: 1164645479
Provider Name (Legal Business Name): FAMILY MEDICINE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 06/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 GILMORE DR
AMORY MS
38821-5414
US

IV. Provider business mailing address

404 GILMORE DR
AMORY MS
38821-3416
US

V. Phone/Fax

Practice location:
  • Phone: 662-256-3564
  • Fax: 662-256-3996
Mailing address:
  • Phone: 662-256-3564
  • Fax: 662-256-3996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHY LINLEY
Title or Position: ADMIN ASSIST
Credential:
Phone: 662-256-7112