Provider Demographics
NPI:1508057076
Name:DELTA HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:DELTA HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIRMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-741-2358
Mailing Address - Street 1:702 MARTIN LUTHER KING ROAD
Mailing Address - Street 2:POST OFFICE BOX 900
Mailing Address - City:MOUND BAYOU
Mailing Address - State:MS
Mailing Address - Zip Code:38762-0900
Mailing Address - Country:US
Mailing Address - Phone:662-335-3991
Mailing Address - Fax:662-332-1736
Practice Address - Street 1:1414 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-3217
Practice Address - Country:US
Practice Address - Phone:662-335-3991
Practice Address - Fax:662-332-1736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014251Medicaid
MS09014251Medicaid