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394 Imperial Ln Sw Bogue Chitto MS 39629-8231 | |
| (601) 996-1758 | |
| (601) 797-8406 |
| Full Name | |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 394 Imperial Ln Sw, Bogue Chitto, Mississippi |
| Authorized Official Name and Position | Khari Abayomi Omolara (MEDICAL DIRECTOR) |
| Authorized Official Contact | 6019961758 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 3129 Brookhaven MS 39603-7129 Ph: (601) 996-1758 | 394 Imperial Ln Sw Bogue Chitto MS 39629-8231 Ph: (601) 996-1758 |
| NPI Number | 1811367113 |
|---|---|
| Provider Enumeration Date | 09/29/2015 |
| Last Update Date | 03/04/2024 |
| Certification Date | 03/04/2024 |
| Medicare PECOS PAC ID | 6002113784 |
|---|---|
| Medicare Enrollment ID | O20160323001364 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1811367113 | NPI | - | NPPES |
| 2522183 | Medicaid | LA | |
| 3663198 | Medicaid | LA | |
| 000126454 | Medicaid | MS | |
| 009120058 | Medicaid | MS |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084P0800X | Psychiatry & Neurology - Psychiatry | (* (Not Available)) | Primary |
| Provider Name | Khari Abayomi Omolara |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1477669380 PECOS PAC ID: 7517944903 Enrollment ID: I20040702000784 |