Provider Demographics
NPI:1902906258
Name:INDIANOLA CLINIC, LLC
Entity Type:Organization
Organization Name:INDIANOLA CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:MARLIN
Authorized Official - Last Name:WOMACK
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:662-686-4121
Mailing Address - Street 1:201 BAKER BLVD
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38756-3401
Mailing Address - Country:US
Mailing Address - Phone:662-686-4121
Mailing Address - Fax:662-686-4770
Practice Address - Street 1:201 BAKER BLVD
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:MS
Practice Address - Zip Code:38756-3401
Practice Address - Country:US
Practice Address - Phone:662-686-4121
Practice Address - Fax:662-686-4770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00459821Medicaid
MS00459821Medicaid