Provider Demographics
NPI:1780395632
Name:MALLORY COMMUNITY HEALTH
Entity type:Organization
Organization Name:MALLORY COMMUNITY HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REVENUE CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LATRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-834-0752
Mailing Address - Street 1:17280 HIGHWAY 17 SOUTH
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MS
Mailing Address - Zip Code:39095
Mailing Address - Country:US
Mailing Address - Phone:662-834-0532
Mailing Address - Fax:
Practice Address - Street 1:175 LEXINGTON STREET
Practice Address - Street 2:
Practice Address - City:PICKENS
Practice Address - State:MS
Practice Address - Zip Code:39146
Practice Address - Country:US
Practice Address - Phone:662-834-0752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MALLORY COMMUNITY HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-12-12
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)