Healthcare Provider Details

I. General information

NPI: 1265464556
Provider Name (Legal Business Name): CENTRAL MISSISSIPPI CIVIC IMPROVEMENT ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 09/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3312 OAK ST
VICKSBURG MS
39180-5042
US

IV. Provider business mailing address

3502 W NORTHSIDE DR
JACKSON MS
39213-4454
US

V. Phone/Fax

Practice location:
  • Phone: 601-629-9500
  • Fax: 601-638-9044
Mailing address:
  • Phone: 601-362-5321
  • Fax: 601-364-2600

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: DR. JASMIN CHAMPMAN
Title or Position: CEO
Credential: DDS
Phone: 601-362-5321