Provider Demographics
NPI:1124481791
Name:FAMILY CARE CLINIC, PLLC
Entity type:Organization
Organization Name:FAMILY CARE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAMONICA
Authorized Official - Middle Name:ANTONETTE
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:662-820-7780
Mailing Address - Street 1:PO BOX 3946
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38704-3946
Mailing Address - Country:US
Mailing Address - Phone:662-820-7780
Mailing Address - Fax:888-980-6547
Practice Address - Street 1:1440 HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-7140
Practice Address - Country:US
Practice Address - Phone:662-820-7780
Practice Address - Fax:888-980-6547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901388261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09551264Medicaid