Provider Demographics
NPI:1073272795
Name:FAST PACE MISSISSIPPI, PLLC
Entity Type:Organization
Organization Name:FAST PACE MISSISSIPPI, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SYDNI
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-351-1791
Mailing Address - Street 1:PO BOX 306415
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37230-6415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5713 HIGHWAY 45 ALT S
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:MS
Practice Address - Zip Code:39773-0414
Practice Address - Country:US
Practice Address - Phone:931-253-1101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health