Provider Demographics
NPI:1629267653
Name:GRACE & MERCY FAMILY MEDICAL CLINIC, PLLC
Entity Type:Organization
Organization Name:GRACE & MERCY FAMILY MEDICAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ODOM-FUNCHES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-373-1055
Mailing Address - Street 1:2106 RAYMOND RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39212-2300
Mailing Address - Country:US
Mailing Address - Phone:601-373-1055
Mailing Address - Fax:601-373-1774
Practice Address - Street 1:2106 RAYMOND RD
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39212-2300
Practice Address - Country:US
Practice Address - Phone:601-373-1055
Practice Address - Fax:601-373-1774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty