Organization
INDIANOLA CLINIC, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
HENRY MARLIN WOMACK JR. (VP OF ADMINISTRATION)
(662) 686-4121
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
261QR1300X
Rural Health Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00459821
—
MS
Enumeration date
09/25/2006
Last updated
07/21/2022
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