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General NPI Number Information
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NPI Number | 1568633964
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Entity Type | Organization
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Legal Business Name | SHANNON FAMILY MEDICAL CLINIC, LLC
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Dates
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Enumeration Date | 03/13/2008
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Last Update Date | 06/25/2018
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Provider Practice Location Address
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Address Line | 219 BROAD ST
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City | SHANNON
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State | MS
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Zip | 38868
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Country | US
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Telephone | 662-995-2201
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Fax | 662-995-2202
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Provider Business Mailing Address
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Address Line | 219 BROAD ST
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City | SHANNON
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State | MS
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Zip | 38868-9301
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Country | US
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Telephone | 662-995-2201
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Fax | 662-995-2202
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Authorized Official
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Title or Position | OWNER
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Name | NORRIS N DOSS
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Credential | FNP
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Telephone | 662-995-2201
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number | R819576
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License Number State | MS
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