Organization
INDIANOLA CLINIC, LLC
Active
Other names
Leland Medical Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
MR. HENRY MARLIN WOMACK JR. (VP OF ADMINISTRATION)
(662) 686-3916
Entity
Organization
Contact information
Practice address
201 BAKER BLVD, LELAND, MS 38756-3401
(662) 686-4121
(662) 686-4770
Mailing address
201 BAKER BLVD, LELAND, MS 38756-3401
(662) 686-4121
(662) 686-4770
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
—
—
104100000X
Social Worker
—
—
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
09889724
—
MS
Enumeration date
11/16/2016
Last updated
05/18/2017
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