Basic Information
| Provider Information | |||||||||
| NPI: | 1104348606 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MALLORY COMMUNITY HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DR. ARENIA C. MALLORY COMMUNITY HEALTH CENTER, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 479 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390950479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628340532 | ||||||||
| FaxNumber: | 6628340531 | ||||||||
| Practice Location | |||||||||
| Address1: | 9479 BROZVILLE RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390957090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628340532 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | CHAPMAN | ||||||||
| AuthorizedOfficialFirstName: | CLYDE | ||||||||
| AuthorizedOfficialMiddleName: | ROZELL | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6628340532 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MALLORY COMMUNITY HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.