Provider Demographics
NPI:1770525057
Name:VOICE OF CALVARY FAMILY HEALTH CENTER INC
Entity type:Organization
Organization Name:VOICE OF CALVARY FAMILY HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PRIMAUS
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-984-8467
Mailing Address - Street 1:350 W WOODROW WILSON AVE
Mailing Address - Street 2:SUITE 615
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-7681
Mailing Address - Country:US
Mailing Address - Phone:601-982-0673
Mailing Address - Fax:601-713-2851
Practice Address - Street 1:350 W WOODROW WILSON AVE
Practice Address - Street 2:SUITE 611
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7681
Practice Address - Country:US
Practice Address - Phone:601-713-3233
Practice Address - Fax:601-713-2851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18106305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS25-1964OtherFQHC CMS CCN
MS08753398Medicaid
MSCO2181Medicare PIN