Healthcare Provider Details

I. General information

NPI: 1275977357
Provider Name (Legal Business Name): IMANI COMMUNITY OUT REACH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2013
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 N JACKSON ST
KOSCIUSKO MS
39090-3322
US

IV. Provider business mailing address

308 N JACKSON ST
KOSCIUSKO MS
39090-3322
US

V. Phone/Fax

Practice location:
  • Phone: 662-289-7676
  • Fax: 662-289-7688
Mailing address:
  • Phone: 662-289-7676
  • Fax: 662-289-7688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name: MISS ALLIE GLEE NDIAYE
Title or Position: CEO
Credential: LPN
Phone: 662-289-7676