Provider Demographics
NPI:1104348606
Name:MALLORY COMMUNITY HEALTH
Entity type:Organization
Organization Name:MALLORY COMMUNITY HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:ROZELL
Authorized Official - Last Name:CHAPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-834-0532
Mailing Address - Street 1:PO BOX 479
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MS
Mailing Address - Zip Code:39095-0479
Mailing Address - Country:US
Mailing Address - Phone:662-834-0532
Mailing Address - Fax:662-834-0531
Practice Address - Street 1:9479 BROZVILLE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MS
Practice Address - Zip Code:39095-7090
Practice Address - Country:US
Practice Address - Phone:662-834-0532
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MALLORY COMMUNITY HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)