Provider Demographics
NPI:1952610826
Name:THE HEART CLINIC, LLC
Entity Type:Organization
Organization Name:THE HEART CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-936-5311
Mailing Address - Street 1:1040 RIVER OAKS DR
Mailing Address - Street 2:SUITE 100 PROFESSIONAL CENTER
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9530
Mailing Address - Country:US
Mailing Address - Phone:601-936-5311
Mailing Address - Fax:
Practice Address - Street 1:1040 RIVER OAKS DR
Practice Address - Street 2:SUITE 100 PROFESSIONAL CENTER
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9530
Practice Address - Country:US
Practice Address - Phone:601-936-5311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14934174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty