Provider Demographics
NPI:1063938520
Name:MID-SOUTH CONVENIENT CARE, PLLC
Entity type:Organization
Organization Name:MID-SOUTH CONVENIENT CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-286-1900
Mailing Address - Street 1:1445 US HIGHWAY 51 BYP E STE B
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-2127
Mailing Address - Country:US
Mailing Address - Phone:731-286-1900
Mailing Address - Fax:731-286-1939
Practice Address - Street 1:1445 US HIGHWAY 51 BYP E STE B
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-2127
Practice Address - Country:US
Practice Address - Phone:731-286-1900
Practice Address - Fax:731-286-1900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health