Provider Demographics
NPI:1407025711
Name:DAVID ALAN TIMM
Entity Type:Organization
Organization Name:DAVID ALAN TIMM
Other - Org Name:PEDIATRIC & ADOLESCENT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MGR
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:P
Authorized Official - Last Name:RIFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-442-7676
Mailing Address - Street 1:308 HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4611
Mailing Address - Country:US
Mailing Address - Phone:601-442-7676
Mailing Address - Fax:601-442-9590
Practice Address - Street 1:1806 CARTER STREET
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-3115
Practice Address - Country:US
Practice Address - Phone:318-336-7172
Practice Address - Fax:318-336-7172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1021849Medicaid
LA1021849Medicaid