Provider Demographics
NPI:1881859338
Name:CLAIBORNE COUNTY FAMILY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:CLAIBORNE COUNTY FAMILY HEALTH CENTER, INC.
Other - Org Name:P G MIDDLE SCHOOL SCHOOL BASE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LADONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-437-3050
Mailing Address - Street 1:2045 HIGHWAY 61 N
Mailing Address - Street 2:P O BOX 741
Mailing Address - City:PORT GIBSON
Mailing Address - State:MS
Mailing Address - Zip Code:39150-4262
Mailing Address - Country:US
Mailing Address - Phone:601-437-9021
Mailing Address - Fax:601-437-3051
Practice Address - Street 1:161 RAMSEY DR
Practice Address - Street 2:2045 HIGHWAY 61 NORTH
Practice Address - City:PORT GIBSON
Practice Address - State:MS
Practice Address - Zip Code:39150-2531
Practice Address - Country:US
Practice Address - Phone:601-437-9021
Practice Address - Fax:601-437-3051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03907367Medicaid
MS251963Medicare Oscar/Certification