Provider Demographics
NPI:1013034636
Name:MALLORY COMMUNITY HEALTH
Entity Type:Organization
Organization Name:MALLORY COMMUNITY HEALTH
Other - Org Name:DR. ARENIA C. MALLORY COMMUNITY HEALTH CENTER, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:ROZELL
Authorized Official - Last Name:CHAPMAN
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:662-834-1857
Mailing Address - Street 1:PO BOX 479
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MS
Mailing Address - Zip Code:39095-0479
Mailing Address - Country:US
Mailing Address - Phone:662-834-1857
Mailing Address - Fax:662-834-4937
Practice Address - Street 1:276 NISSAN PARKWAY, BUILDING C
Practice Address - Street 2:SUITE 100
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046
Practice Address - Country:US
Practice Address - Phone:601-855-5275
Practice Address - Fax:601-859-3253
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015635Medicaid
MS251878Medicare Oscar/Certification