| Organization Name: | YALOBUSHA MEDICAL CLINIC, LLC |
| NPI Number: | 1295090009 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | CINNAMON FOSTER (SOLE MEMBER) |
| Mailing Address: | 712 S Main St Water Valley |
| State: | MS US |
| Postal Code: | 389653334 |
| Phone Number: | 6628321520 |
| Fax Number: | 6624731138 |
| NPI Enumeration Date: | 07/08/2012 |
| NPI Last Update Date: | 07/20/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2300X |
| License Number: | R872547 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MS |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |