Provider Demographics
NPI:1689231367
Name:CHRIST UNITED MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:CHRIST UNITED MEDICAL CLINIC LLC
Other - Org Name:CHRIST UNITED MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FNP-C, CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:CAMERON
Authorized Official - Last Name:WHITEHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:662-446-9012
Mailing Address - Street 1:9573 HIGHWAY 490
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-9192
Mailing Address - Country:US
Mailing Address - Phone:662-446-9012
Mailing Address - Fax:
Practice Address - Street 1:2750 N CHURCH AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339-2054
Practice Address - Country:US
Practice Address - Phone:662-446-9012
Practice Address - Fax:662-446-9432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-28
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSR866227OtherAPRN LIC