Basic Information
| Provider Information | |||||||||
| NPI: | 1033186333 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLIANCE HEALTH PARTNERS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TRI LAKES PEDIATRIC CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 731804 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753731804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6625637873 | ||||||||
| FaxNumber: | 6625638129 | ||||||||
| Practice Location | |||||||||
| Address1: | 435 HIGHWAY 6 E | ||||||||
| Address2: | |||||||||
| City: | BATESVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386063001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6625637873 | ||||||||
| FaxNumber: | 6625638129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2006 | ||||||||
| LastUpdateDate: | 04/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | HERRON | ||||||||
| AuthorizedOfficialFirstName: | JENNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | HMPN | ||||||||
| AuthorizedOfficialTelephone: | 6625635611 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 09013323 | 05 | MS | MEDICAID | C03436 | 01 | MS | CAHABA | OTHER |