Healthcare Provider Details

I. General information

NPI: 1790284693
Provider Name (Legal Business Name): THE CLARKDALE CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2018
Last Update Date: 02/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6905 HIGHWAY 145 S
MERIDIAN MS
39301-9771
US

IV. Provider business mailing address

4715 24TH PL
MERIDIAN MS
39305-1686
US

V. Phone/Fax

Practice location:
  • Phone: 601-696-6736
  • Fax: 601-696-6778
Mailing address:
  • Phone: 601-696-6736
  • Fax: 601-696-6778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WANDA PIERCE
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 601-781-8677