Provider Demographics
NPI:1861673139
Name:TREESAP CLINIC, INC.
Entity Type:Organization
Organization Name:TREESAP CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-223-0063
Mailing Address - Street 1:28301 HIGHWAY 15
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:MS
Mailing Address - Zip Code:38683-9753
Mailing Address - Country:US
Mailing Address - Phone:662-223-0063
Mailing Address - Fax:662-223-0079
Practice Address - Street 1:28301 HIGHWAY 15
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:MS
Practice Address - Zip Code:38683-9753
Practice Address - Country:US
Practice Address - Phone:662-223-0063
Practice Address - Fax:662-223-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR732656261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1265451991OtherINDIVIDUAL NPI
MS03333061Medicaid
MS03333061Medicaid
500001993Medicare PIN