Healthcare Provider Details

I. General information

NPI: 1013034636
Provider Name (Legal Business Name): MALLORY COMMUNITY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

276 NISSAN PARKWAY, BUILDING C SUITE 100
CANTON MS
39046
US

IV. Provider business mailing address

PO BOX 479
LEXINGTON MS
39095-0479
US

V. Phone/Fax

Practice location:
  • Phone: 601-855-5275
  • Fax: 601-859-3253
Mailing address:
  • Phone: 662-834-1857
  • Fax: 662-834-4937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. CLYDE ROZELL CHAPMAN II
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MD
Phone: 662-834-1857