Provider Demographics
NPI:1487118733
Name:EAST-END FAMILY MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:EAST-END FAMILY MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:LATASHA
Authorized Official - Last Name:SHEPARD
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:662-545-4674
Mailing Address - Street 1:1500 N BAYOU RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-9723
Mailing Address - Country:US
Mailing Address - Phone:662-721-8036
Mailing Address - Fax:
Practice Address - Street 1:140 NORTH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2744
Practice Address - Country:US
Practice Address - Phone:662-545-4674
Practice Address - Fax:662-545-4715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-30
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care