Healthcare Provider Details

I. General information

NPI: 1891907093
Provider Name (Legal Business Name): COMMUNITY FAMILY HEALTHCARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 IVIE LANE
MANTACHIE MS
38855
US

IV. Provider business mailing address

285 IVIE LANE
MANTACHIE MS
38855
US

V. Phone/Fax

Practice location:
  • Phone: 662-282-4197
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR857240
License Number StateMS

VIII. Authorized Official

Name: JOY LODEN
Title or Position: OWNER
Credential: CFNP
Phone: 662-282-4197