Provider Demographics
NPI:1326433178
Name:GSV CARE MEDICAL CLINIC OF SHERMAN, LLC
Entity Type:Organization
Organization Name:GSV CARE MEDICAL CLINIC OF SHERMAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
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:662-269-2151
Mailing Address - Street 1:P.O. BOX 302
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:MS
Mailing Address - Zip Code:38869
Mailing Address - Country:US
Mailing Address - Phone:662-269-2151
Mailing Address - Fax:662-269-2129
Practice Address - Street 1:670 HIGHWAY 178 W
Practice Address - Street 2:SUITE 5
Practice Address - City:SHERMAN
Practice Address - State:MS
Practice Address - Zip Code:38869-7000
Practice Address - Country:US
Practice Address - Phone:662-269-2151
Practice Address - Fax:662-269-2129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-30
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01332041Medicaid