Provider Demographics
NPI:1912193459
Name:CRAWFORD HEALTH CLINIC, LLC
Entity Type:Organization
Organization Name:CRAWFORD HEALTH CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FELICIA
Authorized Official - Middle Name:DELORIS
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:662-435-7800
Mailing Address - Street 1:PO BOX 95
Mailing Address - Street 2:
Mailing Address - City:CRAWFORD
Mailing Address - State:MS
Mailing Address - Zip Code:39743-0095
Mailing Address - Country:US
Mailing Address - Phone:662-435-7800
Mailing Address - Fax:
Practice Address - Street 1:15865 HIGHWAY 14
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MS
Practice Address - Zip Code:39341
Practice Address - Country:US
Practice Address - Phone:662-435-7800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR740067261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03825275Medicaid