1740650969 NPI number — IMANI COMMUNITY CENTER

Table of content: (NPI 1740650969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740650969 NPI number — IMANI COMMUNITY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IMANI COMMUNITY CENTER
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:
1740650969
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
207 POPLAR ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KOSCIUSKO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39090-4409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-633-1513
Provider Business Mailing Address Fax Number:
662-289-1010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 POPLAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KOSCIUSKO
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-803-1254
Provider Business Practice Location Address Fax Number:
662-289-1010
Provider Enumeration Date:
09/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
NDIAYE
Authorized Official First Name:
ALLIE
Authorized Official Middle Name:
G
Authorized Official Title or Position:
REGISTERED NURSE
Authorized Official Telephone Number:
662-803-1254

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  08533763 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: 0050750 , 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: 1457623118 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1275977357 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245502962 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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