Provider Demographics
NPI:1205243649
Name:NEWSOM HEALTHCARE OF DESOTO COUNTY, LLC
Entity type:Organization
Organization Name:NEWSOM HEALTHCARE OF DESOTO COUNTY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:MATTHEWS
Authorized Official - Last Name:NEWSOM
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-393-8022
Mailing Address - Street 1:2906 GOODMAN RD W
Mailing Address - Street 2:SUITE 109
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-1291
Mailing Address - Country:US
Mailing Address - Phone:662-393-8022
Mailing Address - Fax:662-393-8052
Practice Address - Street 1:2906 GOODMAN RD W
Practice Address - Street 2:SUITE 109
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-1291
Practice Address - Country:US
Practice Address - Phone:662-393-8022
Practice Address - Fax:662-393-8052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR852706261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117535Medicaid
MS00117535Medicaid
MSS78544Medicare UPIN