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General NPI Number Information
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NPI Number | 1487792032
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Entity Type | Organization
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Legal Business Name | BETHANY MEDICAL CLINIC, LLC
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Dates
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Enumeration Date | 02/02/2007
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Last Update Date | 03/09/2010
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Provider Practice Location Address
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Address Line | 548 EAST ROSEMARY ROAD SUITE B
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City | CLEVELAND
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State | MS
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Zip | 38732
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Country | US
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Telephone | 662-846-5032
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Fax | 662-846-5034
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Provider Business Mailing Address
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Address Line | PO BOX 358
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City | CLEVELAND
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State | MS
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Zip | 38732-0358
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Country | US
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Telephone | 662-846-5032
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Fax | 662-846-5034
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Authorized Official
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Title or Position | INS. CLERK
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Name | MR. RICKY MOORE
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Credential |
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Telephone | 662-846-5032
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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 | R793654
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License Number State | MS
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