Organization Name: | KID'S CLINIC, PLLC |
NPI Number: | 1477642791 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | TAMMY N HENDERSON (OWNER) |
Mailing Address: | 9325c Highway 19 N Collinsville |
State: | MS US |
Postal Code: | 393259219 |
Phone Number: | 6014272752 |
Fax Number: | 6014272800 |
NPI Enumeration Date: | 10/12/2006 |
NPI Last Update Date: | 06/04/2013 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | 13886 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MS |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |