Healthcare Provider Details

I. General information

NPI: 1992256499
Provider Name (Legal Business Name): SARDIS FAMILY MEDICAL CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 S MAIN ST
SARDIS MS
38666-1721
US

IV. Provider business mailing address

124 SOUTH MAIN ST.
SARDIS MS
38666
US

V. Phone/Fax

Practice location:
  • Phone: 662-487-1064
  • Fax:
Mailing address:
  • Phone: 662-487-1064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number901574
License Number StateMS

VIII. Authorized Official

Name: LORI CRAIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 662-487-1064