Provider Demographics
NPI:1033598503
Name:WINSTON MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:WINSTON MEDICAL CLINIC LLC
Other - Org Name:WINSTON MEDICAL CLINIC MAIN STREET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CLINIC OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:FRYERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-446-1972
Mailing Address - Street 1:16569 W MAIN ST
Mailing Address - Street 2:PO BOX 470
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-2620
Mailing Address - Country:US
Mailing Address - Phone:662-773-5704
Mailing Address - Fax:662-773-9463
Practice Address - Street 1:16569 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339
Practice Address - Country:US
Practice Address - Phone:662-773-5704
Practice Address - Fax:662-773-9463
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WINSTON MEDICAL CLINIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-29
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03335534Medicaid
MS299269Medicare Oscar/Certification