Provider Demographics
NPI:1083265284
Name:KIDZ 1ST CLINIC, LLC
Entity Type:Organization
Organization Name:KIDZ 1ST CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:ALLISON
Authorized Official - Last Name:BOWEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP-PC
Authorized Official - Phone:662-532-1543
Mailing Address - Street 1:321 E FIFTEENTH ST
Mailing Address - Street 2:
Mailing Address - City:YAZOO CITY
Mailing Address - State:MS
Mailing Address - Zip Code:39194-2631
Mailing Address - Country:US
Mailing Address - Phone:662-532-1543
Mailing Address - Fax:662-532-1544
Practice Address - Street 1:321 E FIFTEENTH ST
Practice Address - Street 2:
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194-2631
Practice Address - Country:US
Practice Address - Phone:662-532-1543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-27
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty