Organization Name: | FAMILY HEALTH CLINIC OF GRENADA |
NPI Number: | 1144400607 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | HENRY BRISTER (OWNER) |
Mailing Address: | 1117 Sunset Dr Ste 104 Grenada |
State: | MS US |
Postal Code: | 389014080 |
Phone Number: | 6622260110 |
Fax Number: | 6622263700 |
NPI Enumeration Date: | 11/13/2007 |
NPI Last Update Date: | 04/01/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LF0000X |
License Number: | R875035 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MS |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Family |
Taxonomy Definition: |