# WEAVER CLINIC, LLC

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

## Provider details

- **NPI number:** 1366841066
- **Authorized official:** BEVERLY POUNDERS WEAVER FNP (MEDICAL SUPERVISOR)
- **Authorized official phone:** (901) 262-0185

## Contact information

- **Practice address:** 124 W COMMERCE ST, HERNANDO, MS 38632-2240
- **Practice address phone:** (901) 262-0185
- **Mailing address:** 124 W COMMERCE ST, HERNANDO, MS 38632-2240
- **Mailing address phone:** (901) 262-0185

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261Q00000X | Clinic/Center | R629189 | MS | Yes |

## Other

- **Enumeration date:** 08/19/2014
- **Last updated:** 12/01/2014

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 00122952 | — | MS |