Provider Demographics
NPI:1164499174
Name:SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.
Entity Type:Organization
Organization Name:SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC.
Other - Org Name:LUMBERTON FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-545-8700
Mailing Address - Street 1:P O BOX 1729
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:MS
Mailing Address - Zip Code:39455-0000
Mailing Address - Country:US
Mailing Address - Phone:601-796-4215
Mailing Address - Fax:601-796-9437
Practice Address - Street 1:598 W 11TH AVE
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:MS
Practice Address - Zip Code:39455-2350
Practice Address - Country:US
Practice Address - Phone:601-796-4215
Practice Address - Fax:601-796-9437
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST MISSISSIPPI RURAL HEALTH INITIATIVE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-08
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014804Medicaid
MS2704664OtherMS UNITED HEALTH CARE
MSC02142OtherCAHABA MEDICARE GR NUMBER
MS09014804Medicaid