Provider Demographics
NPI:1083009450
Name:NORTH MISSISSIPPI PRIMARY HEALTH CARE, INC.
Entity Type:Organization
Organization Name:NORTH MISSISSIPPI PRIMARY HEALTH CARE, INC.
Other - Org Name:BOONEVILLE COMMUNITY HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:NUNNALLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-224-8951
Mailing Address - Street 1:15921 BOUNDARY DR
Mailing Address - Street 2:PO BOX 92
Mailing Address - City:ASHLAND
Mailing Address - State:MS
Mailing Address - Zip Code:38603-7740
Mailing Address - Country:US
Mailing Address - Phone:662-224-8951
Mailing Address - Fax:662-224-6801
Practice Address - Street 1:208 N 1ST ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-2718
Practice Address - Country:US
Practice Address - Phone:662-728-3313
Practice Address - Fax:662-728-5623
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH MISSISSIPPI PRIMARY HEALTH CARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-02
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09011971Medicaid
MS251877Medicare PIN