Provider Demographics
NPI:1588091714
Name:WINSTON MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:WINSTON MEDICAL CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINIC OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:FRYERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-446-1972
Mailing Address - Street 1:PO BOX 470
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-0470
Mailing Address - Country:US
Mailing Address - Phone:662-446-1972
Mailing Address - Fax:662-446-1039
Practice Address - Street 1:90 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:NOXAPATER
Practice Address - State:MS
Practice Address - Zip Code:39346
Practice Address - Country:US
Practice Address - Phone:662-724-4051
Practice Address - Fax:662-724-4054
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WINSTON MEDICAL CLINIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-02
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health