Healthcare Provider Details

I. General information

NPI: 1902031123
Provider Name (Legal Business Name): GREENE AREA MEDICAL EXTENDERS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2009
Last Update Date: 05/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 CHURCH STREET
STATE LINE MS
39451
US

IV. Provider business mailing address

P O BOX 160
LEAKESVILLE MS
39451-0160
US

V. Phone/Fax

Practice location:
  • Phone: 601-848-7650
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: JOE DAWSEY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 601-394-2381