Healthcare Provider Details

I. General information

NPI: 1457321036
Provider Name (Legal Business Name): PHC-CLEVELAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 06/10/2025
Certification Date: 06/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E SUNFLOWER RD
CLEVELAND MS
38732-2833
US

IV. Provider business mailing address

680 S 4TH ST
LOUISVILLE KY
40202-2407
US

V. Phone/Fax

Practice location:
  • Phone: 662-846-0061
  • Fax: 662-846-2380
Mailing address:
  • Phone:
  • Fax: 502-212-8481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number16224
License Number StateMS

VIII. Authorized Official

Name: JOHNETTA TRAYLOR
Title or Position: DIRECTOR
Credential: PESC
Phone: 502-596-6063