Provider Demographics
NPI:1740650969
Name:IMANI COMMUNITY CENTER
Entity type:Organization
Organization Name:IMANI COMMUNITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED NURSE
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:ETC
Authorized Official - Phone:662-803-1254
Mailing Address - Street 1:207 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-4409
Mailing Address - Country:US
Mailing Address - Phone:662-633-1513
Mailing Address - Fax:662-289-1010
Practice Address - Street 1:207 POPLAR ST
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39339
Practice Address - Country:US
Practice Address - Phone:662-803-1254
Practice Address - Fax:662-289-1010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0050750101YM0800X
MS08533763305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1457623118Medicaid
MS1275977357Medicaid
MS1245502962Medicaid