Healthcare Provider Details

I. General information

NPI: 1023885050
Provider Name (Legal Business Name): HARRIS FAMILY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 E WASHINGTON ST
HOUSTON MS
38851-2318
US

IV. Provider business mailing address

403 E WASHINGTON ST
HOUSTON MS
38851-2318
US

V. Phone/Fax

Practice location:
  • Phone: 662-792-6601
  • Fax: 406-315-7338
Mailing address:
  • Phone: 662-792-6601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ARETHA RENEE HARRIS
Title or Position: PROVIDER
Credential: FNP-C
Phone: 662-631-4316