Healthcare Provider Details

I. General information

NPI: 1174294797
Provider Name (Legal Business Name): TENN-TOM MED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

369 HIGHWAY 72
BURNSVILLE MS
38833-9320
US

IV. Provider business mailing address

PO BOX 214
BURNSVILLE MS
38833-0214
US

V. Phone/Fax

Practice location:
  • Phone: 662-427-4040
  • Fax: 662-427-4041
Mailing address:
  • Phone: 662-427-4040
  • Fax: 662-427-4041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CAMILLE WHITEHEAD
Title or Position: MANAGING NURSE PRACTITIONER
Credential: NP
Phone: 662-427-4040