Provider Demographics
NPI:1093835209
Name:THE MEDICAL CLINIC OF DESOTO INC
Entity Type:Organization
Organization Name:THE MEDICAL CLINIC OF DESOTO INC
Other - Org Name:THE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GBEMUDU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-893-0450
Mailing Address - Street 1:6953 OAK FOREST DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1920
Mailing Address - Country:US
Mailing Address - Phone:662-893-0450
Mailing Address - Fax:662-893-0460
Practice Address - Street 1:6953 OAK FOREST DR
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1920
Practice Address - Country:US
Practice Address - Phone:662-893-0450
Practice Address - Fax:662-893-0460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care