Basic Information
| Provider Information | |||||||||
| NPI: | 1770515058 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL MISSISSIPPI CIVIC IMPROVEMENT ASSOCIATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COPIAH COMPREHENSIVE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3502 W. NORTHSIDE DRIVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013625321 | ||||||||
| FaxNumber: | 6013645159 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 CALDWELL DRIVE | ||||||||
| Address2: | |||||||||
| City: | HAZLEHURST | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018941448 | ||||||||
| FaxNumber: | 6018942903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 05/12/2009 | ||||||||
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| AuthorizedOfficialLastName: | CHAPMAN | ||||||||
| AuthorizedOfficialFirstName: | JASMIN | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6013625321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 09016170 | 05 | MS | MEDICAID |