Healthcare Provider Details

I. General information

NPI: 1053439133
Provider Name (Legal Business Name): MALLORY COMMUNITY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 03/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201A MAGNOLIA ST
VAIDEN MS
39176-5644
US

IV. Provider business mailing address

PO BOX 369
VAIDEN MS
39176-0369
US

V. Phone/Fax

Practice location:
  • Phone: 662-464-5470
  • Fax: 662-464-0152
Mailing address:
  • Phone: 662-464-5470
  • Fax: 662-464-0152

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: MR. DEWERY MONTGOMERY
Title or Position: INTERIM CEO
Credential:
Phone: 662-834-1857