# ROLLING FORK MEDICAL CLINIC, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1275174971
- **Authorized official:** LISA THOMAS HEARN (MANAGER)
- **Authorized official phone:** (662) 335-4105

## Contact information

- **Practice address:** 44 S FOURTH ST, ROLLING FORK, MS 39159-5147
- **Practice address phone:** (662) 335-4105
- **Practice address fax:** (662) 378-2879
- **Mailing address:** 1997 MEDICAL PARK DR, GREENVILLE, MS 38703-7268
- **Mailing address phone:** (662) 335-4105
- **Mailing address fax:** (662) 335-4105

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |

## Other

- **Enumeration date:** 10/03/2019
- **Last updated:** 10/03/2019