Basic Information
| Provider Information | |||||||||
| NPI: | 1205425535 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MALLORY COMMUNITY HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 479 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390950479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628341857 | ||||||||
| FaxNumber: | 6628341859 | ||||||||
| Practice Location | |||||||||
| Address1: | 17280 HIGHWAY 17 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390956614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628341857 | ||||||||
| FaxNumber: | 6628341859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2021 | ||||||||
| LastUpdateDate: | 01/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | MABRY | ||||||||
| AuthorizedOfficialFirstName: | LATONYA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6628340746 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 12/30/2020 | ||||||||
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.