Healthcare Provider Details

I. General information

NPI: 1245506377
Provider Name (Legal Business Name): CRAWFORD MOBILE HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15865 HIGHWAY 14 WEST
MACON MS
39341-0402
US

IV. Provider business mailing address

PO BOX 95
CRAWFORD MS
39743-0095
US

V. Phone/Fax

Practice location:
  • Phone: 662-435-7800
  • Fax:
Mailing address:
  • Phone: 662-435-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberR740067
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License NumberR740067
License Number StateMS

VIII. Authorized Official

Name: FELICIA DELORIS EDWARDS
Title or Position: MANAING PARTNER
Credential: NP
Phone: 662-435-7800