Provider Demographics
NPI:1265088421
Name:DELTA HEALTH CENTER, INC
Entity type:Organization
Organization Name:DELTA HEALTH CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HR-CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MYRTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-741-8889
Mailing Address - Street 1:702 MARTIN LUTHER KING ST
Mailing Address - Street 2:
Mailing Address - City:MOUND BAYOU
Mailing Address - State:MS
Mailing Address - Zip Code:38762-9314
Mailing Address - Country:US
Mailing Address - Phone:662-745-8892
Mailing Address - Fax:662-745-6228
Practice Address - Street 1:400 SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:DREW
Practice Address - State:MS
Practice Address - Zip Code:38737-3508
Practice Address - Country:US
Practice Address - Phone:662-745-8892
Practice Address - Fax:662-745-6228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013118Medicaid