=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508393000
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDIANOLA WELLNESS CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2017
-----------------------------------------------------
Last Update Date | 06/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 131 MAIN ST
-----------------------------------------------------
City | INDIANOLA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38751-2849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-303-3743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 108 WHITTINGTON DR
-----------------------------------------------------
City | INDIANOLA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38751-3434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-303-3743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER/OWNER
-----------------------------------------------------
Name | MS. KAJUANDRA K CHANDLER
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 662-303-3743
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 901379
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------