Healthcare Provider Details

I. General information

NPI: 1306393830
Provider Name (Legal Business Name): THAXTON MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11145 HIGHWAY 6 WEST
THAXTON MS
38871
US

IV. Provider business mailing address

PO BOX 99
THAXTON MS
38871-0099
US

V. Phone/Fax

Practice location:
  • Phone: 662-489-8500
  • Fax:
Mailing address:
  • Phone: 662-489-8500
  • Fax: 662-489-8600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number23667
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR850403
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number901698
License Number StateMS

VIII. Authorized Official

Name: MRS. ELIZABETH BROOKE HOOKER
Title or Position: OWNER/
Credential: RT
Phone: 662-489-8500