Provider Demographics
NPI:1194854208
Name:SHAW COMMUNITY CARE CLINIC
Entity Type:Organization
Organization Name:SHAW COMMUNITY CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARLA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-332-8848
Mailing Address - Street 1:PO BOX 5097
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38704-5097
Mailing Address - Country:US
Mailing Address - Phone:662-332-8848
Mailing Address - Fax:
Practice Address - Street 1:112 PEELER AVE
Practice Address - Street 2:
Practice Address - City:SHAW
Practice Address - State:MS
Practice Address - Zip Code:38773
Practice Address - Country:US
Practice Address - Phone:662-754-2060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty