Healthcare Provider Details

I. General information

NPI: 1235133968
Provider Name (Legal Business Name): CLAIBORNE COUNTY FAMILY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2045 HIGHWAY 61 NORTH
PORT GIBSON MS
39150-4262
US

IV. Provider business mailing address

2045 HIGHWAY 61 N P O BOX 741
PORT GIBSON MS
39150-4262
US

V. Phone/Fax

Practice location:
  • Phone: 601-437-3049
  • Fax: 601-437-3051
Mailing address:
  • Phone: 601-437-3049
  • Fax: 601-437-3051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. LADONNA BEASLEY DAVIS
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 601-437-3052