Basic Information
| Provider Information | |||||||||
| NPI: | 1669441994 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREENWOOD LEFLORE HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GREENWOOD CHILDREN'S CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1410 | ||||||||
| Address2: | CLINIC ADMINISTRATION | ||||||||
| City: | GREENWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389351410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6624597030 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1405 STRONG AVE | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 38930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6624597030 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 06/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | HOLMES | ||||||||
| AuthorizedOfficialFirstName: | DAWNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6624597119 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 09015045 | 05 | MS | MEDICAID |