Provider Demographics
NPI:1134137219
Name:LEE COUNTY COOPERATIVE CLINIC
Entity Type:Organization
Organization Name:LEE COUNTY COOPERATIVE CLINIC
Other - Org Name:HUGHES SATELLITE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CASHIER./BILLING SUPERVISOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:OSSIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-295-5225
Mailing Address - Street 1:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:AR
Mailing Address - Zip Code:72360-0669
Mailing Address - Country:US
Mailing Address - Phone:870-295-5225
Mailing Address - Fax:870-295-6900
Practice Address - Street 1:503 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HUGHES
Practice Address - State:AR
Practice Address - Zip Code:72348-9701
Practice Address - Country:US
Practice Address - Phone:870-295-5225
Practice Address - Fax:870-295-6900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR149471749Medicaid