Provider Demographics
NPI:1124505912
Name:THAXTON FAMILY MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:THAXTON FAMILY MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:FLOYD
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:662-213-7890
Mailing Address - Street 1:11145 HIGHWAY 6 W
Mailing Address - Street 2:
Mailing Address - City:THAXTON
Mailing Address - State:MS
Mailing Address - Zip Code:38871-9024
Mailing Address - Country:US
Mailing Address - Phone:662-489-8500
Mailing Address - Fax:662-489-8600
Practice Address - Street 1:11145 HIGHWAY 6 W
Practice Address - Street 2:
Practice Address - City:THAXTON
Practice Address - State:MS
Practice Address - Zip Code:38871-9024
Practice Address - Country:US
Practice Address - Phone:662-489-8500
Practice Address - Fax:662-489-8600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901818261QP2300X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care