Provider Demographics
NPI:1669749081
Name:IMANI COMMUNITY OUTREACH CTR
Entity type:Organization
Organization Name:IMANI COMMUNITY OUTREACH CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:B
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-878-6945
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:2011-11-30
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00686258Medicaid