Provider Demographics
NPI:1922032812
Name:MARIETTA FAMILY CLINIC, INC.
Entity Type:Organization
Organization Name:MARIETTA FAMILY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SLACK
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:662-728-2408
Mailing Address - Street 1:PO BOX 56
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:MS
Mailing Address - Zip Code:38856-0056
Mailing Address - Country:US
Mailing Address - Phone:662-728-2408
Mailing Address - Fax:662-728-2409
Practice Address - Street 1:3 CR 4050
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:MS
Practice Address - Zip Code:38856
Practice Address - Country:US
Practice Address - Phone:662-728-2408
Practice Address - Fax:662-728-2409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853095363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03282808Medicaid
MS03282808Medicaid