Provider Demographics
NPI:1851798961
Name:SPECIALTY CARE EXTENDED HOURS CLINIC LLC
Entity Type:Organization
Organization Name:SPECIALTY CARE EXTENDED HOURS CLINIC LLC
Other - Org Name:SPECIALTY CARE EXTENDED HOURS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCKAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-634-8641
Mailing Address - Street 1:5600 GOODMAN RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-7002
Mailing Address - Country:US
Mailing Address - Phone:901-634-8641
Mailing Address - Fax:662-420-7147
Practice Address - Street 1:5600 GOODMAN RD
Practice Address - Street 2:SUITE D
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-7002
Practice Address - Country:US
Practice Address - Phone:901-634-8641
Practice Address - Fax:662-420-7147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-04
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty