=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417253642
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOPE MEDICAL CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2011
-----------------------------------------------------
Last Update Date | 02/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3223 AUDUBON DR
-----------------------------------------------------
City | LAUREL
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39440-1422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-425-3020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3223 AUDUBON DR
-----------------------------------------------------
City | LAUREL
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39440-1422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-425-3020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LINDY CASSELL
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 601-425-3020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | R865733
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------