Provider Demographics
NPI:1275874281
Name:GSV CARE MEDICAL CLINIC
Entity Type:Organization
Organization Name:GSV CARE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:662-983-0422
Mailing Address - Street 1:400 THIRD AVENUE
Mailing Address - Street 2:
Mailing Address - City:HOULKA
Mailing Address - State:MS
Mailing Address - Zip Code:38850
Mailing Address - Country:US
Mailing Address - Phone:662-568-2013
Mailing Address - Fax:662-568-2023
Practice Address - Street 1:400 THIRD AVENUE
Practice Address - Street 2:
Practice Address - City:HOULKA
Practice Address - State:MS
Practice Address - Zip Code:38850
Practice Address - Country:US
Practice Address - Phone:662-568-2013
Practice Address - Fax:662-568-2023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-15
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR850148261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04506555Medicaid