Organization
BETHANY MEDICAL CLINIC, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RICKY MOORE (INS. CLERK)
(662) 846-5032
Entity
Organization
Contact information
Practice address
548 EAST ROSEMARY ROAD, SUITE B, CLEVELAND, MS 38732
(662) 846-5032
(662) 846-5034
Mailing address
PO BOX 358, CLEVELAND, MS 38732-0358
(662) 846-5032
(662) 846-5034
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
R793654
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
07021837
—
MS
Enumeration date
02/02/2007
Last updated
03/09/2010
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