Provider Demographics
NPI:1275977357
Name:IMANI COMMUNITY OUT REACH CENTER
Entity Type:Organization
Organization Name:IMANI COMMUNITY OUT REACH CENTER
Other - Org Name:IMAMI COMMUNITY CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:ALLIE
Authorized Official - Middle Name:GLEE
Authorized Official - Last Name:NDIAYE
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:662-289-7676
Mailing Address - Street 1:308 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-3322
Mailing Address - Country:US
Mailing Address - Phone:662-289-7676
Mailing Address - Fax:662-289-7688
Practice Address - Street 1:308 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3322
Practice Address - Country:US
Practice Address - Phone:662-289-7676
Practice Address - Fax:662-289-7688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-19
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS261QA0600XOther1172V00000X
MS261QA0600XMedicaid
MS26QA0600XMedicaid
MS261QM1300XMedicaid
MS261QA0600XOther1172V00000X
MS26QA0600XMedicaid
MS261QA0600XMedicaid
MS172V00000XMedicare PIN
26IQM1300XMedicare PIN
MS261QA06000XMedicare PIN