Provider Demographics
NPI:1396127221
Name:CONVENIENT CARE MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:CONVENIENT CARE MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:662-241-7177
Mailing Address - Street 1:PO BOX 9051
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-0015
Mailing Address - Country:US
Mailing Address - Phone:662-251-3565
Mailing Address - Fax:
Practice Address - Street 1:2207 5TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2211
Practice Address - Country:US
Practice Address - Phone:662-251-3565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-27
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01903235Medicaid