Provider Demographics
NPI:1720589070
Name:MANTACHIE RURAL HEALTH CARE INC BEHAVIORAL HEALTH
Entity Type:Organization
Organization Name:MANTACHIE RURAL HEALTH CARE INC BEHAVIORAL HEALTH
Other - Org Name:MANTACHIE RURAL HEALTH CARE INC BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:CRABB
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-282-4226
Mailing Address - Street 1:5510 HWY 363
Mailing Address - Street 2:
Mailing Address - City:MANTACHIE
Mailing Address - State:MS
Mailing Address - Zip Code:38855
Mailing Address - Country:US
Mailing Address - Phone:662-282-4226
Mailing Address - Fax:662-282-7946
Practice Address - Street 1:5510 HWY 363
Practice Address - Street 2:
Practice Address - City:MANTACHIE
Practice Address - State:MS
Practice Address - Zip Code:38855
Practice Address - Country:US
Practice Address - Phone:662-282-4226
Practice Address - Fax:662-282-7946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-22
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08581013Medicaid