Healthcare Provider Details

I. General information

NPI: 1740650969
Provider Name (Legal Business Name): IMANI COMMUNITY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 POPLAR ST
KOSCIUSKO MS
39339
US

IV. Provider business mailing address

207 POPLAR ST
KOSCIUSKO MS
39090-4409
US

V. Phone/Fax

Practice location:
  • Phone: 662-803-1254
  • Fax: 662-289-1010
Mailing address:
  • Phone: 662-633-1513
  • Fax: 662-289-1010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0050750
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number08533763
License Number StateMS

VIII. Authorized Official

Name: MS. ALLIE G NDIAYE I
Title or Position: REGISTERED NURSE
Credential: ETC.
Phone: 662-803-1254