Provider Demographics
NPI:1952163206
Name:PEDIATRIC & ADOLESCENT CLINIC LLC
Entity Type:Organization
Organization Name:PEDIATRIC & ADOLESCENT CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:TIMM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-442-7676
Mailing Address - Street 1:308 HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4611
Mailing Address - Country:US
Mailing Address - Phone:601-442-7676
Mailing Address - Fax:601-442-9590
Practice Address - Street 1:107 N MARTIN LUTHER KING JR ST
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-3356
Practice Address - Country:US
Practice Address - Phone:601-442-7676
Practice Address - Fax:601-442-9590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-23
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty