Provider Demographics
NPI:1295174555
Name:IMANI COMMUNITY OUT REACH CENTER
Entity type:Organization
Organization Name:IMANI COMMUNITY OUT REACH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ALLIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:NDIAYE
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:662-289-7676
Mailing Address - Street 1:301 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-3719
Mailing Address - Country:US
Mailing Address - Phone:662-289-7676
Mailing Address - Fax:
Practice Address - Street 1:301 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3719
Practice Address - Country:US
Practice Address - Phone:662-289-7676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS7862305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
261QA0600XOtherADULT DAY CARE
MS08533763OtherHOSPICE
MS172V00000XOtherCLINIC SOCIAL WORKER
261QA0600XOtherADULT DAY CARE
MS172V00000XOtherCLINIC SOCIAL WORKER