Healthcare Provider Details

I. General information

NPI: 1619063815
Provider Name (Legal Business Name): GREENE RURAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 JACKSON AVE
LEAKESVILLE MS
39451-9105
US

IV. Provider business mailing address

1017 JACKSON AVE
LEAKESVILLE MS
39451-9105
US

V. Phone/Fax

Practice location:
  • Phone: 601-394-4135
  • Fax: 601-394-4455
Mailing address:
  • Phone: 601-394-4135
  • Fax: 601-394-4455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number11343
License Number StateMS

VIII. Authorized Official

Name: DONNA FREEMAN
Title or Position: FACILITY ADMINISTRATOR
Credential:
Phone: 601-394-4135