Provider Demographics
NPI:1871918789
Name:OLIVE BRANCH PRIMARY CARE, PLLC
Entity type:Organization
Organization Name:OLIVE BRANCH PRIMARY CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:M
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-895-3700
Mailing Address - Street 1:1405 NOTTINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9474
Mailing Address - Country:US
Mailing Address - Phone:662-349-0406
Mailing Address - Fax:662-349-0406
Practice Address - Street 1:7163 GOODMAN RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1904
Practice Address - Country:US
Practice Address - Phone:662-895-3700
Practice Address - Fax:662-895-4886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-28
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center