Healthcare Provider Details

I. General information

NPI: 1588853154
Provider Name (Legal Business Name): FAMILY HEALTH CARE CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2007
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 WHITEOAK AVE
RALEIGH MS
39153
US

IV. Provider business mailing address

PO BOX 24116
JACKSON MS
39225-4116
US

V. Phone/Fax

Practice location:
  • Phone: 601-825-7280
  • Fax: 601-825-8130
Mailing address:
  • Phone: 601-825-7280
  • Fax: 601-825-8130

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: KARINA MARIE CLAYTON
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 601-825-7280