Provider Demographics
NPI:1144400607
Name:FAMILY HEALTH CLINIC OF GRENADA
Entity Type:Organization
Organization Name:FAMILY HEALTH CLINIC OF GRENADA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRISTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-226-0110
Mailing Address - Street 1:1117 SUNSET DR STE 104
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-4080
Mailing Address - Country:US
Mailing Address - Phone:662-226-0110
Mailing Address - Fax:662-226-3700
Practice Address - Street 1:1117 SUNSET DR STE 104
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4080
Practice Address - Country:US
Practice Address - Phone:662-226-0110
Practice Address - Fax:662-226-3700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR875035363LF0000X
MSR742805363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01476010Medicaid
MS01476010Medicaid