Provider Demographics
NPI:1306393830
Name:THAXTON MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:THAXTON MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:BROOKE
Authorized Official - Last Name:HOOKER
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:662-489-8500
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:THAXTON
Mailing Address - State:MS
Mailing Address - Zip Code:38871-0099
Mailing Address - Country:US
Mailing Address - Phone:662-489-8500
Mailing Address - Fax:662-489-8600
Practice Address - Street 1:11145 HIGHWAY 6 WEST
Practice Address - Street 2:
Practice Address - City:THAXTON
Practice Address - State:MS
Practice Address - Zip Code:38871
Practice Address - Country:US
Practice Address - Phone:662-489-8500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR850403363L00000X
MS901698363L00000X
MS23667261QP2300X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty