Basic Information
| Provider Information | |||||||||
| NPI: | 1093731234 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY HEALTH CARE CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24116 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392254116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018257280 | ||||||||
| FaxNumber: | 6018258130 | ||||||||
| Practice Location | |||||||||
| Address1: | 430 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | MONTICELLO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396547723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015874492 | ||||||||
| FaxNumber: | 6015877138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | GRAY | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 6018257280 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPA | ||||||||
| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | MS | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 09014309 | 05 | MS | MEDICAID |