Provider Demographics
NPI:1003191867
Name:GLUCKSTADT SPECIAL CARE CLINIC
Entity Type:Organization
Organization Name:GLUCKSTADT SPECIAL CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLIENT SOLUTIONS
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:M
Authorized Official - Last Name:CONNER
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:318-255-7591
Mailing Address - Street 1:1716 HIGHWAY 51 STE M
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-5020
Mailing Address - Country:US
Mailing Address - Phone:601-707-5621
Mailing Address - Fax:601-707-9052
Practice Address - Street 1:1716 HIGHWAY 51 STE M
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-5020
Practice Address - Country:US
Practice Address - Phone:601-707-5621
Practice Address - Fax:601-707-9052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care