Provider Demographics
NPI:1598904377
Name:HL CAMPBELL RURAL HEALTH CLINIC
Entity Type:Organization
Organization Name:HL CAMPBELL RURAL HEALTH CLINIC
Other - Org Name:HL CAMPBELL RURAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:VANELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-398-5004
Mailing Address - Street 1:PO BOX 1507
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-1507
Mailing Address - Country:US
Mailing Address - Phone:662-398-5004
Mailing Address - Fax:
Practice Address - Street 1:901 FOREST STREET
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:MS
Practice Address - Zip Code:38774
Practice Address - Country:US
Practice Address - Phone:662-398-5004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09586879Medicaid
MS09586879Medicaid