Provider Demographics
NPI:1831288281
Name:FAITH FAMILY CLINIC, LLC
Entity Type:Organization
Organization Name:FAITH FAMILY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER/CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:BERNICE
Authorized Official - Last Name:THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, BC
Authorized Official - Phone:662-415-0270
Mailing Address - Street 1:2209 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-7734
Mailing Address - Country:US
Mailing Address - Phone:662-728-0162
Mailing Address - Fax:
Practice Address - Street 1:2209 N 2ND ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-7734
Practice Address - Country:US
Practice Address - Phone:662-728-0162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care