Basic Information
| Provider Information | |||||||||
| NPI: | 1770696213 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YAZOO FAMILY HEALTHCARE,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 307 E FIFTEENTH ST | ||||||||
| Address2: | |||||||||
| City: | YAZOO CITY | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391942631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627462113 | ||||||||
| FaxNumber: | 6627462115 | ||||||||
| Practice Location | |||||||||
| Address1: | 307 E FIFTEENTH ST | ||||||||
| Address2: | |||||||||
| City: | YAZOO CITY | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391942631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627462113 | ||||||||
| FaxNumber: | 6627462115 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 06/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | LEDLOW | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6627462113 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 425460633B | 01 | MS | BLUE CROSS BLUE SHIELD | OTHER | 03278771 | 05 | MS | MEDICAID | 587229770A | 01 | MS | BLUE CROSS BLUE SHIELD | OTHER | 00124725 | 05 | MS | MEDICAID | 587571939 | 01 | MS | BLUE CROSS BLUE SHIELD | OTHER | 0011803 | 05 | MS | MEDICAID | 00126250 | 05 | MS | MEDICAID |