Provider Demographics
NPI:1124275581
Name:FAMILY CLINIC FOR HEALTH & WELLNESS, LLC.
Entity type:Organization
Organization Name:FAMILY CLINIC FOR HEALTH & WELLNESS, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:CAPRICE
Authorized Official - Last Name:CHANDLER
Authorized Official - Suffix:
Authorized Official - Credentials:FNPC
Authorized Official - Phone:601-445-5556
Mailing Address - Street 1:55 SERGEANT PRENTISS DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4782
Mailing Address - Country:US
Mailing Address - Phone:601-445-5556
Mailing Address - Fax:
Practice Address - Street 1:55 SERGEANT PRENTISS DR
Practice Address - Street 2:SUITE 104
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4782
Practice Address - Country:US
Practice Address - Phone:601-445-5556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR850771363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02833234Medicaid