Healthcare Provider Details

I. General information

NPI: 1154670719
Provider Name (Legal Business Name): INDEPENDENT HEALTHCARE MANAGEMENT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2012
Last Update Date: 05/26/2020
Certification Date: 05/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 HIGHWAY 35 S SUITE 1
FOREST MS
39074-8829
US

IV. Provider business mailing address

1129 HIGHWAY 35 S SUITE 1
FOREST MS
39074-8829
US

V. Phone/Fax

Practice location:
  • Phone: 601-849-6440
  • Fax: 601-849-1318
Mailing address:
  • Phone: 601-849-6440
  • Fax: 601-849-1318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number13-033
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN P LEE
Title or Position: CHAIRMAN OF THE BOARD
Credential:
Phone: 601-849-6440