Healthcare Provider Details

I. General information

NPI: 1659378610
Provider Name (Legal Business Name): DELTA HEALTH CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2005
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date: 07/17/2007
Reactivation Date: 08/08/2007

III. Provider practice location address

702 MARTIN LUTHER KING ROAD
MOUND BAYOU MS
38762-9314
US

IV. Provider business mailing address

702 MARTIN LUTHER KING ST POST OFFICE BOX 900
MOUND BAYOU MS
38762-0900
US

V. Phone/Fax

Practice location:
  • Phone: 662-741-2151
  • Fax: 662-741-2700
Mailing address:
  • Phone: 662-741-2151
  • Fax: 662-741-2700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. JOHN FAIRMAN
Title or Position: CEO
Credential: CEO
Phone: 662-741-2151