Basic Information
| Provider Information | |||||||||
| NPI: | 1740624881 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MALLORY COMMUNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DR. ARENIA C. MALLORY COMMUNITY HEALTH CENTER, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | POST OFFICE BOX 479 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390950479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628341857 | ||||||||
| FaxNumber: | 6628344937 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 YAZOO STREET | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628345000 | ||||||||
| FaxNumber: | 6628345003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2013 | ||||||||
| LastUpdateDate: | 07/21/2016 | ||||||||
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| AuthorizedOfficialLastName: | CHAPMAN | ||||||||
| AuthorizedOfficialFirstName: | CLYDE | ||||||||
| AuthorizedOfficialMiddleName: | ROZELL | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6628341857 | ||||||||
| 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) |
ID Information
| ID | Type | State | Issuer | Description | 00474061 | 05 | MS | MEDICAID |