Provider Demographics
NPI:1003875394
Name:GREENWOOD LEFLORE HOSPITAL
Entity Type:Organization
Organization Name:GREENWOOD LEFLORE HOSPITAL
Other - Org Name:ITTA BENA CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:DAWNE
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-459-2603
Mailing Address - Street 1:PO BOX 1410
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38935-1410
Mailing Address - Country:US
Mailing Address - Phone:662-254-7801
Mailing Address - Fax:
Practice Address - Street 1:103 BASKET ST
Practice Address - Street 2:
Practice Address - City:ITTA BENA
Practice Address - State:MS
Practice Address - Zip Code:38941-2801
Practice Address - Country:US
Practice Address - Phone:662-254-7801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014635Medicaid
DF5855OtherMEDICARE RAILROAD
MS=========OtherBLUE CROSS BLUE SHIELD
250099OtherMEDICARE PART A
CO2955Medicare PIN
MS09014635Medicaid