Provider Demographics
NPI:1003844978
Name:THE GREENVILLE CLINIC
Entity Type:Organization
Organization Name:THE GREENVILLE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-379-8141
Mailing Address - Street 1:1502 S COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-7219
Mailing Address - Country:US
Mailing Address - Phone:662-332-9872
Mailing Address - Fax:662-332-9878
Practice Address - Street 1:1502 S COLORADO ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-7219
Practice Address - Country:US
Practice Address - Phone:662-332-9872
Practice Address - Fax:662-332-9878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2500316731OtherCLIA
MS9014413Medicaid
MSCD3504OtherRAILROAD MEDICARE
MS9014413Medicaid