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General NPI Number Information
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NPI Number | 1346544376
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Entity Type | Organization
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Legal Business Name | FAMILY MEDICAL CLINIC OF CLEVELAND, LLC
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Dates
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Enumeration Date | 01/05/2011
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Last Update Date | 01/05/2011
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Provider Practice Location Address
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Address Line | 803 1ST ST
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City | CLEVELAND
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State | MS
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Zip | 38732-2309
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Country | US
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Telephone | 662-843-2721
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Fax | 662-846-1728
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Provider Business Mailing Address
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Address Line | 803 1ST ST
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City | CLEVELAND
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State | MS
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Zip | 38732-2309
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Country | US
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Telephone | 662-843-2721
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Fax | 662-846-1728
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Authorized Official
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Title or Position | PRESIDENT
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Name | DONALD JAMES BLACKWOOD
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Credential | M.D.
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Telephone | 662-843-2721
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | R855837
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License Number State | MS
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