Provider Demographics
NPI:1518237932
Name:IUKA TOWN CLINIC, LLC
Entity Type:Organization
Organization Name:IUKA TOWN CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:SHAREE
Authorized Official - Last Name:TILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-423-5007
Mailing Address - Street 1:109 E QUITMAN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-1936
Mailing Address - Country:US
Mailing Address - Phone:662-423-5007
Mailing Address - Fax:662-423-5050
Practice Address - Street 1:109 E QUITMAN ST
Practice Address - Street 2:SUITE A
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-1936
Practice Address - Country:US
Practice Address - Phone:662-423-5007
Practice Address - Fax:662-423-5050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-02
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS989911363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty