Provider Demographics
NPI:1164607552
Name:FAMILY HEALTH CARE CLINIC, INC.
Entity Type:Organization
Organization Name:FAMILY HEALTH CARE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KARINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CLAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-825-7280
Mailing Address - Street 1:PO BOX 24116
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-4116
Mailing Address - Country:US
Mailing Address - Phone:601-825-7280
Mailing Address - Fax:601-825-8130
Practice Address - Street 1:1551 W GOVERNMENT ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39042
Practice Address - Country:US
Practice Address - Phone:601-825-3163
Practice Address - Fax:601-825-7893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2018-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X
MS2036-831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014312Medicaid