Healthcare Provider Details

I. General information

NPI: 1508312992
Provider Name (Legal Business Name): MALLORY COMMUNITY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 12/30/2020
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17280 HIGHWAY 17
LEXINGTON MS
39095-6614
US

IV. Provider business mailing address

PO BOX 479
LEXINGTON MS
39095-0479
US

V. Phone/Fax

Practice location:
  • Phone: 662-834-1857
  • Fax: 662-834-1859
Mailing address:
  • Phone: 662-834-1857
  • Fax: 662-834-1859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. CLYDE ROZELL CHAPMAN II
Title or Position: CHIEF EXEXCUTIVE OFFICER
Credential: M.D.
Phone: 662-834-1857