Provider Demographics
NPI:1780715912
Name:TOCCOPOLA FAMILY MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:TOCCOPOLA FAMILY MEDICAL CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:POOLE
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:662-281-8003
Mailing Address - Street 1:P.O. BOX 389
Mailing Address - Street 2:
Mailing Address - City:TOCCOPOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38874-0389
Mailing Address - Country:US
Mailing Address - Phone:662-281-8003
Mailing Address - Fax:662-281-8020
Practice Address - Street 1:7908 HWY 334
Practice Address - Street 2:
Practice Address - City:TOCCOPOLA
Practice Address - State:MS
Practice Address - Zip Code:38874-0389
Practice Address - Country:US
Practice Address - Phone:662-281-8020
Practice Address - Fax:662-281-8020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR549002363LF0000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014299Medicaid
MS253960Medicare Oscar/Certification
MS09014299Medicaid