Provider Demographics
NPI:1326380189
Name:HICKORY FLAT CLINIC, LLC
Entity Type:Organization
Organization Name:HICKORY FLAT CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-551-6492
Mailing Address - Street 1:6492 BECK SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:HICKORY FLAT
Mailing Address - State:MS
Mailing Address - Zip Code:38633-9116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 OAK ST
Practice Address - Street 2:
Practice Address - City:HICKORY FLAT
Practice Address - State:MS
Practice Address - Zip Code:38633
Practice Address - Country:US
Practice Address - Phone:662-551-6492
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR855906261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09426886Medicaid
MS09426886Medicaid