Healthcare Provider Details

I. General information

NPI: 1093058968
Provider Name (Legal Business Name): FAMILY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2013
Last Update Date: 03/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 S 11TH AVE
LAUREL MS
39440-4312
US

IV. Provider business mailing address

117 S 11TH AVE
LAUREL MS
39440-4312
US

V. Phone/Fax

Practice location:
  • Phone: 601-425-3033
  • Fax: 601-428-6561
Mailing address:
  • Phone: 601-425-3033
  • Fax: 601-428-6561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License NumberR872330
License Number StateMS

VIII. Authorized Official

Name: MRS. LADONNA MICHELLE BRANCH
Title or Position: CERTIFIED NURSE PRACTIONER
Credential: FNP
Phone: 601-425-3033