Healthcare Provider Details

I. General information

NPI: 1053576819
Provider Name (Legal Business Name): LEAKE MEMORIAL MEDICAL CLINIC WALNUT GROVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 PARK ST
WALNUT GROVE MS
39189-6526
US

IV. Provider business mailing address

PO BOX 367
WALNUT GROVE MS
39189-0367
US

V. Phone/Fax

Practice location:
  • Phone: 601-267-1400
  • Fax: 601-253-9464
Mailing address:
  • Phone: 601-267-1400
  • Fax: 601-253-9464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: KRISTI ESTEP
Title or Position: OFFICE MANAGER
Credential:
Phone: 601-267-1400