Provider Demographics
NPI:1942962816
Name:GAUTIER FAMILY CLINIC, LLC
Entity Type:Organization
Organization Name:GAUTIER FAMILY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOLEWARE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:601-800-8580
Mailing Address - Street 1:MARCIA EASTERWOOD
Mailing Address - Street 2:P.O. BOX 177
Mailing Address - City:ELLISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39437
Mailing Address - Country:US
Mailing Address - Phone:601-800-8580
Mailing Address - Fax:601-800-8583
Practice Address - Street 1:4533B GAUTIER VANCLEAVE RD
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553
Practice Address - Country:US
Practice Address - Phone:228-202-5924
Practice Address - Fax:228-202-5918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty