Provider Demographics
NPI:1629417324
Name:WINSTON MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:WINSTON MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINIC OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:FRYERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-446-1972
Mailing Address - Street 1:P O BOX 470
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339
Mailing Address - Country:US
Mailing Address - Phone:662-773-3503
Mailing Address - Fax:662-446-1039
Practice Address - Street 1:923 S CHURCH AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339
Practice Address - Country:US
Practice Address - Phone:662-773-3503
Practice Address - Fax:662-446-1039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-17
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01689827Medicaid
MS258593Medicare Oscar/Certification