Provider Demographics
NPI:1447893888
Name:SPECTRUM THE OTHER CLINIC
Entity type:Organization
Organization Name:SPECTRUM THE OTHER CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STACIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:PACE
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:601-466-9495
Mailing Address - Street 1:2910 MAGNOLIA PL
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-2428
Mailing Address - Country:US
Mailing Address - Phone:601-466-9495
Mailing Address - Fax:601-469-9965
Practice Address - Street 1:709 HARDY ST
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-3666
Practice Address - Country:US
Practice Address - Phone:601-466-9495
Practice Address - Fax:601-469-9965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-17
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty