Provider Demographics
NPI:1508393000
Name:INDIANOLA WELLNESS CLINIC, LLC
Entity Type:Organization
Organization Name:INDIANOLA WELLNESS CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAJUANDRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:CHANDLER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:662-303-3743
Mailing Address - Street 1:108 WHITTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751-3434
Mailing Address - Country:US
Mailing Address - Phone:662-303-3743
Mailing Address - Fax:
Practice Address - Street 1:131 MAIN ST
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:MS
Practice Address - Zip Code:38751-2849
Practice Address - Country:US
Practice Address - Phone:662-303-3743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-15
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901379261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03321871Medicaid