Healthcare Provider Details

I. General information

NPI: 1679673917
Provider Name (Legal Business Name): INDIANOLA CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 BAKER BLVD
LELAND MS
38756-3401
US

IV. Provider business mailing address

201 BAKER BLVD
LELAND MS
38756-3401
US

V. Phone/Fax

Practice location:
  • Phone: 662-686-4121
  • Fax: 662-686-4770
Mailing address:
  • Phone: 662-686-4121
  • Fax: 662-686-4770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateMS

VIII. Authorized Official

Name: AMY MCINTIRE
Title or Position: DIRECTOR
Credential:
Phone: 662-686-3956