MEDICARE: FAST PACE MISSISSIPPI, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1326705518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAST PACE MISSISSIPPI, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 306415
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37230-6415
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1417 HIGHWAY 1 S
Second Line	:
City	:	GREENVILLE
State	:	MS
Zip	:	38701-7141
Country	:	US
Telephone Number	:	662-430-2451
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	SYDNI CLEMMONS
Credential	:
Telephone Number	:	901-351-1791

Provider Enumeration Date	:	11/22/2021
Last Update Date	:	11/22/2021

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