Provider Demographics
NPI:1760420335
Name:CENTRAL MISSISSIPPI CIVIC IMPROVEMENT ASSOCIATION, INC
Entity Type:Organization
Organization Name:CENTRAL MISSISSIPPI CIVIC IMPROVEMENT ASSOCIATION, INC
Other - Org Name:COPIAH COMPREHENSIVE HEALTH COMPLEX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JASMIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHAPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:601-362-5321
Mailing Address - Street 1:3502 W NORTHSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213
Mailing Address - Country:US
Mailing Address - Phone:601-362-5321
Mailing Address - Fax:601-364-5159
Practice Address - Street 1:550 CALDWELL DR
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:MS
Practice Address - Zip Code:39083-2304
Practice Address - Country:US
Practice Address - Phone:601-894-1448
Practice Address - Fax:601-894-2903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09016087Medicaid
251896Medicare UPIN
MS09016087Medicaid