Provider Demographics
NPI:1235133968
Name:CLAIBORNE COUNTY FAMILY HEALTH CENTER
Entity Type:Organization
Organization Name:CLAIBORNE COUNTY FAMILY HEALTH CENTER
Other - Org Name:CCFHC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LADONNA
Authorized Official - Middle Name:BEASLEY
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-437-3052
Mailing Address - Street 1:2045 HIGHWAY 61 N
Mailing Address - Street 2:P O BOX 741
Mailing Address - City:PORT GIBSON
Mailing Address - State:MS
Mailing Address - Zip Code:39150-4262
Mailing Address - Country:US
Mailing Address - Phone:601-437-3049
Mailing Address - Fax:601-437-3051
Practice Address - Street 1:2045 HIGHWAY 61 NORTH
Practice Address - Street 2:
Practice Address - City:PORT GIBSON
Practice Address - State:MS
Practice Address - Zip Code:39150-4262
Practice Address - Country:US
Practice Address - Phone:601-437-3049
Practice Address - Fax:601-437-3051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QF0400X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09010054Medicaid
MS251827Medicare Oscar/Certification
MSC00946Medicare UPIN