Provider Demographics
NPI:1518243443
Name:NORTH MISSISSIPPI CLINICS, LLC
Entity Type:Organization
Organization Name:NORTH MISSISSIPPI CLINICS, LLC
Other - Org Name:THE CLINIC AT WALMART OXFORD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMBROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-377-4685
Mailing Address - Street 1:2530 JACKSON AVE W
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5403
Mailing Address - Country:US
Mailing Address - Phone:662-513-6682
Mailing Address - Fax:662-513-6684
Practice Address - Street 1:2530 JACKSON AVE W
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5403
Practice Address - Country:US
Practice Address - Phone:662-513-6682
Practice Address - Fax:662-513-6684
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH MISSISSIPPI CLINICS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-24
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302G086375OtherMEDICARE GROUP