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General NPI Number Information
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NPI Number | 1629267653
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Entity Type | Organization
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Legal Business Name | GRACE & MERCY FAMILY MEDICAL CLINIC, PLLC
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Dates
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Enumeration Date | 10/16/2007
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Last Update Date | 12/10/2012
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Provider Practice Location Address
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Address Line | 2106 RAYMOND RD SUITE A
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City | JACKSON
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State | MS
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Zip | 39212-2300
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Country | US
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Telephone | 601-373-1055
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Fax | 601-373-1774
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Provider Business Mailing Address
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Address Line | 2106 RAYMOND RD SUITE A
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City | JACKSON
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State | MS
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Zip | 39212-2300
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Country | US
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Telephone | 601-373-1055
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Fax | 601-373-1774
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Authorized Official
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Title or Position | OWNER
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Name | DR. RHONDA M. ODOM-FUNCHES
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Credential | M.D.
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Telephone | 601-373-1055
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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