Provider Demographics
NPI:1922174655
Name:SOUTHERN HEALTH CORP. OF HOUSTON, INC.
Entity Type:Organization
Organization Name:SOUTHERN HEALTH CORP. OF HOUSTON, INC.
Other - Org Name:FAMILY MEDICAL CLINIC OF OKOLONA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-456-3700
Mailing Address - Street 1:521 WEST DR
Mailing Address - Street 2:
Mailing Address - City:OKOLONA
Mailing Address - State:MS
Mailing Address - Zip Code:38860-1625
Mailing Address - Country:US
Mailing Address - Phone:662-447-1405
Mailing Address - Fax:662-447-1408
Practice Address - Street 1:518 WEST DR
Practice Address - Street 2:
Practice Address - City:OKOLONA
Practice Address - State:MS
Practice Address - Zip Code:38860-1624
Practice Address - Country:US
Practice Address - Phone:662-447-1405
Practice Address - Fax:662-447-1408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07728748Medicaid
MSC02044Medicare PIN
MS080004343Medicare PIN
MSD80494Medicare UPIN
MS25-8542Medicare PIN