Healthcare Provider Details

I. General information

NPI: 1275874281
Provider Name (Legal Business Name): GSV CARE MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2013
Last Update Date: 03/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 THIRD AVENUE
HOULKA MS
38850
US

IV. Provider business mailing address

400 THIRD AVENUE
HOULKA MS
38850
US

V. Phone/Fax

Practice location:
  • Phone: 662-568-2013
  • Fax: 662-568-2023
Mailing address:
  • Phone: 662-568-2013
  • Fax: 662-568-2023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License NumberR850148
License Number StateMS

VIII. Authorized Official

Name: MRS. MANDA GRIFFIN
Title or Position: OWNER
Credential: DNP
Phone: 662-983-0422