Provider Demographics
NPI:1457544066
Name:FAMILY WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:FAMILY WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:S
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-437-5668
Mailing Address - Street 1:PO BOX 726
Mailing Address - Street 2:
Mailing Address - City:PORT GIBSON
Mailing Address - State:MS
Mailing Address - Zip Code:39150-0726
Mailing Address - Country:US
Mailing Address - Phone:601-437-5668
Mailing Address - Fax:601-437-4533
Practice Address - Street 1:703B FARMER ST
Practice Address - Street 2:
Practice Address - City:PORT GIBSON
Practice Address - State:MS
Practice Address - Zip Code:39150-2319
Practice Address - Country:US
Practice Address - Phone:601-437-5668
Practice Address - Fax:601-437-4533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16897207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122761Medicaid
MS00122761Medicaid
MSH26073Medicare UPIN