Provider Demographics
NPI:1184166035
Name:GRAYSON CREEK MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:GRAYSON CREEK MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MACK
Authorized Official - Middle Name:E
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:601-408-9945
Mailing Address - Street 1:3 JOHN EVERETT RD
Mailing Address - Street 2:
Mailing Address - City:MOSELLE
Mailing Address - State:MS
Mailing Address - Zip Code:39459-9771
Mailing Address - Country:US
Mailing Address - Phone:601-620-9991
Mailing Address - Fax:
Practice Address - Street 1:3 JOHN EVERETT RD
Practice Address - Street 2:
Practice Address - City:MOSELLE
Practice Address - State:MS
Practice Address - Zip Code:39459-9771
Practice Address - Country:US
Practice Address - Phone:601-620-9991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-09
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS732001363LF0000X, 363LP0200X
MS901749363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0044232Medicaid