Provider Demographics
NPI:1679673917
Name:INDIANOLA CLINIC, LLC
Entity Type:Organization
Organization Name:INDIANOLA CLINIC, LLC
Other - Org Name:LELAND MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCINTIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-686-3956
Mailing Address - Street 1:201 BAKER BLVD
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38756
Mailing Address - Country:US
Mailing Address - Phone:662-686-4121
Mailing Address - Fax:662-686-4770
Practice Address - Street 1:201 BAKER BLVD
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:MS
Practice Address - Zip Code:38756
Practice Address - Country:US
Practice Address - Phone:662-686-4121
Practice Address - Fax:662-686-4770
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDIANOLA CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-25
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QR1300X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016086Medicaid
C02625OtherCAHABA - MEDICARE
C02625OtherCAHABA - MEDICARE