Healthcare Provider Details

I. General information

NPI: 1689821126
Provider Name (Legal Business Name): GREENE COUNTY FAMILY MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 JACKSON AVE
LEAKESVILLE MS
39451-9105
US

IV. Provider business mailing address

PO BOX 1007
LUCEDALE MS
39452-1007
US

V. Phone/Fax

Practice location:
  • Phone: 601-394-2820
  • Fax: 601-394-2827
Mailing address:
  • Phone: 601-947-1332
  • Fax: 601-947-1331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number11343
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. KATHY FENDER
Title or Position: ADMINISTRATOR
Credential:
Phone: 601-947-8181