1477009876 NPI number — MALLORY COMMUNITY HEALTH

Table of content: (NPI 1477009876)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477009876 NPI number — MALLORY COMMUNITY HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MALLORY COMMUNITY HEALTH
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:
DR. ARENIA C. MALLORY COMMUNITY HEALTH CENTER, INC.
Provider Other Organization Name Type Code:
5
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:
1477009876
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 479
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39095-0479
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-834-1857
Provider Business Mailing Address Fax Number:
662-834-1859

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14494 HIGHWAY 51
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURANT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39063-9627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-653-6262
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/27/2016

Additional Information

Authorized Official

Authorized Official Last Name:
CHAPMAN
Authorized Official First Name:
CLYDE
Authorized Official Middle Name:
ROZELL
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
662-834-2566

Provider Taxonomy Codes

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

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





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