Provider Demographics
NPI:1467726000
Name:IMANI COMMUNITY OUTREACH CENTER
Entity Type:Organization
Organization Name:IMANI COMMUNITY OUTREACH CENTER
Other - Org Name:IMAMI COMMUNITY CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ALLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NDIAYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-289-7676
Mailing Address - Street 1:308 N JACKSON STREET
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-1453
Mailing Address - Country:US
Mailing Address - Phone:662-289-7676
Mailing Address - Fax:662-289-7688
Practice Address - Street 1:308 N JACKSON STREET
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-1453
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:2012-02-29
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSPENDINGMedicaid