Healthcare Provider Details

I. General information

NPI: 1942574363
Provider Name (Legal Business Name): FAMILY & URGENT CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 03/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 GOODMAN RD W
HORN LAKE MS
38637-1189
US

IV. Provider business mailing address

3040 GOODMAN RD W
HORN LAKE MS
38637-1189
US

V. Phone/Fax

Practice location:
  • Phone: 662-280-3428
  • Fax: 662-280-1736
Mailing address:
  • Phone: 662-280-3428
  • Fax: 662-280-1736

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: BARRY J POLITI
Title or Position: SOLE MBR
Credential:
Phone: 662-280-3428