1235371659 NPI number — FAMILY HEALTH CARE CLINIC, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235371659 NPI number — FAMILY HEALTH CARE CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY HEALTH CARE CLINIC, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235371659
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/03/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 24116
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39225-4116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-825-7280
Provider Business Mailing Address Fax Number:
601-825-8130

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
445 MAIN ST E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEADVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39653
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-825-7280
Provider Business Practice Location Address Fax Number:
601-825-8130
Provider Enumeration Date:
03/31/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CLAYTON
Authorized Official First Name:
KARINA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
601-825-7280

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 08588025 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 251981 . This is a "MEDICARE ID-TYPE UNSPECIFIED" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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