Provider Demographics
NPI:1326186826
Name:ADULTS & CHILDREN MEDICAL CLINIC
Entity Type:Organization
Organization Name:ADULTS & CHILDREN MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:C
Authorized Official - Last Name:THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:PNP ANP
Authorized Official - Phone:662-348-2002
Mailing Address - Street 1:PO BOX 156
Mailing Address - Street 2:
Mailing Address - City:GUNTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:38849-0156
Mailing Address - Country:US
Mailing Address - Phone:662-348-2002
Mailing Address - Fax:662-348-2001
Practice Address - Street 1:571 MITCHELL RD
Practice Address - Street 2:SUITE C
Practice Address - City:GUNTOWN
Practice Address - State:MS
Practice Address - Zip Code:38849-0156
Practice Address - Country:US
Practice Address - Phone:662-348-2002
Practice Address - Fax:662-348-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR519715363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016058Medicaid
MS09016058Medicaid