Provider Demographics
NPI:1154670719
Name:INDEPENDENT HEALTHCARE MANAGEMENT, INC.
Entity Type:Organization
Organization Name:INDEPENDENT HEALTHCARE MANAGEMENT, INC.
Other - Org Name:LACKEY PEDIATRIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-849-6440
Mailing Address - Street 1:1129 HIGHWAY 35 S
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FOREST
Mailing Address - State:MS
Mailing Address - Zip Code:39074-8829
Mailing Address - Country:US
Mailing Address - Phone:601-849-6440
Mailing Address - Fax:601-849-1318
Practice Address - Street 1:1129 HIGHWAY 35 S
Practice Address - Street 2:SUITE 1
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-8829
Practice Address - Country:US
Practice Address - Phone:601-849-6440
Practice Address - Fax:601-849-1318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13-033261Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS13033OtherLICENSE