Provider Demographics
NPI:1053646190
Name:MORE CONVENIENT CARE CENTER LLC
Entity type:Organization
Organization Name:MORE CONVENIENT CARE CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HILLIARD
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, BC, FNP
Authorized Official - Phone:601-209-8432
Mailing Address - Street 1:P. O. BOX 68483
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39286
Mailing Address - Country:US
Mailing Address - Phone:601-321-9104
Mailing Address - Fax:601-321-9138
Practice Address - Street 1:4612 MEDGAR EVERS BLVD
Practice Address - Street 2:SUITE 10
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-5205
Practice Address - Country:US
Practice Address - Phone:601-321-9104
Practice Address - Fax:601-321-9138
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MORE CONVENIENT CARE CENTER LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-07
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR656046261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS500001874OtherMEDICARE
MS00115980Medicaid
MS00115980Medicaid