Provider Demographics
NPI:1104074319
Name:PRIMARY HEALTH CARE, PLLC
Entity type:Organization
Organization Name:PRIMARY HEALTH CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / OPERATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:MOORE
Authorized Official - Last Name:CLINTON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:662-560-4313
Mailing Address - Street 1:565 N ROBINSON ST
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668-2118
Mailing Address - Country:US
Mailing Address - Phone:662-560-4313
Mailing Address - Fax:662-560-4383
Practice Address - Street 1:565 N ROBINSON ST
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-2118
Practice Address - Country:US
Practice Address - Phone:662-560-4313
Practice Address - Fax:662-560-4383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR672491261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS11618104OtherCAQH
MSS19627OtherUPIN
MS00116700Medicaid
MSR672491OtherLICENSE NUMBER
MSR672491OtherLICENSE NUMBER
MSS19627OtherUPIN