Healthcare Provider Details

I. General information

NPI: 1942519517
Provider Name (Legal Business Name): POTTS CAMP FAMILY MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2010
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 REIDS ALLEY
POTTS CAMP MS
38659
US

IV. Provider business mailing address

PO BOX 88
POTTS CAMP MS
38659-0088
US

V. Phone/Fax

Practice location:
  • Phone: 662-333-4333
  • Fax:
Mailing address:
  • Phone: 662-333-4333
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. ALICE STINE
Title or Position: BUSINESS MANAGER
Credential:
Phone: 662-333-4333