Full Name | |
---|---|
Speciality | Clinic/Center |
Location | 9715 Highway 12 W, Tchula, Mississippi |
Authorized Official Name and Position | Clyde Rozell Chapman (CHIEF EXECUTIVE OFFICER) |
Authorized Official Contact | 6628341857 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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Po Box 479 Lexington MS 39095-0479 Ph: (662) 834-1857 | 9715 Highway 12 W Tchula MS 39169 Ph: (662) 235-4731 |
NPI Number | 1881713519 |
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Provider Enumeration Date | 03/27/2007 |
Last Update Date | 07/21/2016 |
Medicare PECOS PAC ID | 9739074501 |
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Medicare Enrollment ID | O20101123000418 |
Identifier | Type | State | Issuer |
---|---|---|---|
1881713519 | NPI | - | NPPES |
09015634 | Medicaid | MS |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |