Healthcare Provider Details

I. General information

NPI: 1518237932
Provider Name (Legal Business Name): IUKA TOWN CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2012
Last Update Date: 03/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 E QUITMAN ST SUITE A
IUKA MS
38852-1936
US

IV. Provider business mailing address

109 E QUITMAN ST SUITE A
IUKA MS
38852-1936
US

V. Phone/Fax

Practice location:
  • Phone: 662-423-5007
  • Fax: 662-423-5050
Mailing address:
  • Phone: 662-423-5007
  • Fax: 662-423-5050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number989911
License Number StateMS

VIII. Authorized Official

Name: MARY SHAREE TILL
Title or Position: OWNER
Credential:
Phone: 662-423-5007