Provider Demographics
NPI:1942758131
Name:INDIANOLA CLINIC, LLC
Entity type:Organization
Organization Name:INDIANOLA CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMIN. ASST. & CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCCAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-686-3916
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:2016-09-15
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X, 261QP2000X, 261QX0100X
MS261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016086Medicaid