MEDICARE: CLAIBORNE COUNTY FAMILY HEALTH CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center
2	261QF0400X	Federally Qualified Health Center (FQHC)		MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235133968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLAIBORNE COUNTY FAMILY HEALTH CENTER

Provider Business Mailing Address
First Line	:	2045 HIGHWAY 61 N
Second Line	:	P O BOX 741
City	:	PORT GIBSON
State	:	MS
Zip	:	39150-4262
Country	:	US
Telephone Number	:	601-437-3049
Fax Number	:	601-437-3051

Provider Business Practice Location Address
First Line	:	2045 HIGHWAY 61 NORTH
Second Line	:
City	:	PORT GIBSON
State	:	MS
Zip	:	39150-4262
Country	:	US
Telephone Number	:	601-437-3049
Fax Number	:	601-437-3051

Authorized Official
Title or Position	:	CHIEF OPERATING OFFICER
Name	:	MRS. LADONNA BEASLEY DAVIS
Credential	:
Telephone Number	:	601-437-3052

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	09/24/2013

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