Provider Demographics
NPI:1164964565
Name:INDIANOLA CLINIC, LLC
Entity Type:Organization
Organization Name:INDIANOLA CLINIC, LLC
Other - Org Name:LELAND MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF ADMINISTRATION
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:MARLIN
Authorized Official - Last Name:WOMACK
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:662-686-3916
Mailing Address - Street 1:201 BAKER BLVD
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38756-3401
Mailing Address - Country:US
Mailing Address - Phone:662-686-4121
Mailing Address - Fax:662-686-4770
Practice Address - Street 1:201 BAKER BLVD
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:MS
Practice Address - Zip Code:38756-3401
Practice Address - Country:US
Practice Address - Phone:662-686-4121
Practice Address - Fax:662-686-4770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-16
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09889724Medicaid
MS250892954Medicare Oscar/Certification