Provider Demographics
NPI:1023474780
Name:WINSTON MEDICAL CLINIC FAIR ELEMENTARY SCHOOL
Entity type:Organization
Organization Name:WINSTON MEDICAL CLINIC FAIR ELEMENTARY SCHOOL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINIC OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:FRYERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-446-1972
Mailing Address - Street 1:PO BOX 470
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-0470
Mailing Address - Country:US
Mailing Address - Phone:662-446-1972
Mailing Address - Fax:552-446-1039
Practice Address - Street 1:301 N COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339-2315
Practice Address - Country:US
Practice Address - Phone:662-446-1972
Practice Address - Fax:662-446-1039
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WINSTON MEDICAL CLINIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR860217363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty