Provider Demographics
NPI:1104574847
Name:AARON E. HENRY COMMUNITY HEALTH
Entity type:Organization
Organization Name:AARON E. HENRY COMMUNITY HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REVENUE CYCLE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:L
Authorized Official - Last Name:FONDREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-624-4292
Mailing Address - Street 1:PO BOX 1216
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-1216
Mailing Address - Country:US
Mailing Address - Phone:662-624-4292
Mailing Address - Fax:662-351-3303
Practice Address - Street 1:600 OHIO AVE
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6020
Practice Address - Country:US
Practice Address - Phone:662-624-4292
Practice Address - Fax:662-351-3303
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AARON E. HENRY COMMUNITY HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-11
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09010039Medicaid