Provider Demographics
NPI:1376143024
Name:DESOTO FAMILY WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:DESOTO FAMILY WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:OLLAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-892-2885
Mailing Address - Street 1:3495 COBBLESTONE BLVD S
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-7075
Mailing Address - Country:US
Mailing Address - Phone:662-892-2885
Mailing Address - Fax:662-892-2889
Practice Address - Street 1:3495 COBBLESTONE BLVD S
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-7075
Practice Address - Country:US
Practice Address - Phone:662-892-2885
Practice Address - Fax:662-892-2889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-30
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty