Provider Demographics
NPI:1710065222
Name:GOLDEN TRIANGLE RURAL FAMILY HEALTH CENTER LLC
Entity Type:Organization
Organization Name:GOLDEN TRIANGLE RURAL FAMILY HEALTH CENTER LLC
Other - Org Name:GTR FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THELMA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:MCCLENTON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-320-7001
Mailing Address - Street 1:1237 HIGHWAY 182 E
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-9529
Mailing Address - Country:US
Mailing Address - Phone:662-320-7001
Mailing Address - Fax:662-320-4830
Practice Address - Street 1:1237 HIGHWAY 182 E
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-9529
Practice Address - Country:US
Practice Address - Phone:662-320-7001
Practice Address - Fax:662-320-4830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00507061Medicaid
Q05462Medicare UPIN
MS00507061Medicaid