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General NPI Number Information
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NPI Number | 1275174971
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Entity Type | Organization
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Legal Business Name | ROLLING FORK MEDICAL CLINIC, LLC
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Dates
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Enumeration Date | 10/03/2019
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Last Update Date | 10/03/2019
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Provider Practice Location Address
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Address Line | 44 S FOURTH ST
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City | ROLLING FORK
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State | MS
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Zip | 39159-5147
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Country | US
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Telephone | 662-335-4105
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Fax | 662-378-2879
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Provider Business Mailing Address
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Address Line | 1997 MEDICAL PARK DR
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City | GREENVILLE
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State | MS
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Zip | 38703-7268
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Country | US
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Telephone | 662-335-4105
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Fax | 662-335-4105
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Authorized Official
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Title or Position | MANAGER
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Name | LISA THOMAS HEARN
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Credential |
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Telephone | 662-335-4105
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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