Provider Demographics
NPI:1003005125
Name:NETTLETON FAMILY MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:NETTLETON FAMILY MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:CURRY
Authorized Official - Last Name:JUSTICE
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:662-963-9146
Mailing Address - Street 1:1495 MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:NETTLETON, MS
Mailing Address - State:MS
Mailing Address - Zip Code:38858-6026
Mailing Address - Country:US
Mailing Address - Phone:662-963-9146
Mailing Address - Fax:662-963-9186
Practice Address - Street 1:1495 MAPLE RD
Practice Address - Street 2:
Practice Address - City:NETTLETON
Practice Address - State:MS
Practice Address - Zip Code:38858-6026
Practice Address - Country:US
Practice Address - Phone:662-963-9146
Practice Address - Fax:662-963-9186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR682403261QP2300X
MSR850606261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00328681Medicaid
MS512G700050Medicare UPIN