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General NPI Number Information
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NPI Number | 1154671824
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Entity Type | Organization
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Legal Business Name | PREMIER FAMILY CLINIC & URGENT CARE LLC
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Dates
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Enumeration Date | 09/10/2012
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Last Update Date | 06/18/2013
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Provider Practice Location Address
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Address Line | 312 PARK PLAZA DR
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City | NEW ALBANY
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State | MS
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Zip | 38652-3104
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Country | US
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Telephone | 662-213-1225
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Fax |
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Provider Business Mailing Address
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Address Line | 312 PARK PLAZA DR
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City | NEW ALBANY
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State | MS
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Zip | 38652-3104
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Country | US
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Telephone | 662-534-8780
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Fax |
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Authorized Official
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Title or Position | PROVIDER/MANAGER
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Name | SHELIA TICE
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Credential | F.N.P.B.C.
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Telephone | 662-534-8780
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | R857901
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License Number State | MS
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