Organization
ROLLING FORK MEDICAL CLINIC, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LISA THOMAS HEARN (MANAGER)
(662) 335-4105
Entity
Organization
Contact information
Practice address
44 S FOURTH ST, ROLLING FORK, MS 39159-5147
(662) 335-4105
(662) 378-2879
Mailing address
1997 MEDICAL PARK DR, GREENVILLE, MS 38703-7268
(662) 335-4105
(662) 335-4105
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
05457590
—
MS
Enumeration date
10/03/2019
Last updated
10/03/2019
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