Provider Demographics
NPI:1053576819
Name:LEAKE MEMORIAL MEDICAL CLINIC WALNUT GROVE
Entity type:Organization
Organization Name:LEAKE MEMORIAL MEDICAL CLINIC WALNUT GROVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:ESTEP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-267-1400
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:WALNUT GROVE
Mailing Address - State:MS
Mailing Address - Zip Code:39189-0367
Mailing Address - Country:US
Mailing Address - Phone:601-267-1400
Mailing Address - Fax:601-253-9464
Practice Address - Street 1:110 PARK ST
Practice Address - Street 2:
Practice Address - City:WALNUT GROVE
Practice Address - State:MS
Practice Address - Zip Code:39189-6526
Practice Address - Country:US
Practice Address - Phone:601-267-1400
Practice Address - Fax:601-253-9464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05874018Medicaid