Basic Information
Provider Information | |||||||||
NPI: | 1477009876 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MALLORY COMMUNITY HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DR. ARENIA C. MALLORY COMMUNITY HEALTH CENTER, INC. | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 479 | ||||||||
Address2: |   | ||||||||
City: | LEXINGTON | ||||||||
State: | MS | ||||||||
PostalCode: | 390950479 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6628341857 | ||||||||
FaxNumber: | 6628341859 | ||||||||
Practice Location | |||||||||
Address1: | 14494 HIGHWAY 51 | ||||||||
Address2: |   | ||||||||
City: | DURANT | ||||||||
State: | MS | ||||||||
PostalCode: | 390639627 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6626536262 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/27/2016 | ||||||||
LastUpdateDate: | 08/27/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHAPMAN | ||||||||
AuthorizedOfficialFirstName: | CLYDE | ||||||||
AuthorizedOfficialMiddleName: | ROZELL | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6628342566 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
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.