Healthcare Provider Details

I. General information

NPI: 1144400607
Provider Name (Legal Business Name): FAMILY HEALTH CLINIC OF GRENADA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 SUNSET DR STE 104
GRENADA MS
38901-4080
US

IV. Provider business mailing address

1117 SUNSET DR STE 104
GRENADA MS
38901-4080
US

V. Phone/Fax

Practice location:
  • Phone: 662-226-0110
  • Fax: 662-226-3700
Mailing address:
  • Phone: 662-226-0110
  • Fax: 662-226-3700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR742805
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR875035
License Number StateMS

VIII. Authorized Official

Name: MR. HENRY BRISTER
Title or Position: OWNER
Credential:
Phone: 662-226-0110