Basic Information
| Provider Information | |||||||||
| NPI: | 1326350240 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHOCTAW COUNTY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHOCTAW MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 119 WEST CHERRY STREET | ||||||||
| Address2: | |||||||||
| City: | ACKERMAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397350000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018491682 | ||||||||
| FaxNumber: | 6018491969 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 WEST CHERRY STREET | ||||||||
| Address2: | |||||||||
| City: | ACKERMAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 397350000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018491682 | ||||||||
| FaxNumber: | 6018491969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2010 | ||||||||
| LastUpdateDate: | 07/08/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HIGGINS | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT OF THE BOARD | ||||||||
| AuthorizedOfficialTelephone: | 6622856329 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | SR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.