Provider Demographics
NPI:1942519517
Name:POTTS CAMP FAMILY MEDICAL CLINIC
Entity Type:Organization
Organization Name:POTTS CAMP FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:STINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-333-4333
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:POTTS CAMP
Mailing Address - State:MS
Mailing Address - Zip Code:38659-0088
Mailing Address - Country:US
Mailing Address - Phone:662-333-4333
Mailing Address - Fax:
Practice Address - Street 1:3 REIDS ALLEY
Practice Address - Street 2:
Practice Address - City:POTTS CAMP
Practice Address - State:MS
Practice Address - Zip Code:38659
Practice Address - Country:US
Practice Address - Phone:662-333-4333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty