Provider Demographics
NPI:1154765808
Name:IMANI COMMUNITY OUTREACH CENTER
Entity type:Organization
Organization Name:IMANI COMMUNITY OUTREACH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALLIE
Authorized Official - Middle Name:GLEE
Authorized Official - Last Name:NDIAYE
Authorized Official - Suffix:I
Authorized Official - Credentials:LPN
Authorized Official - Phone:662-289-7676
Mailing Address - Street 1:301 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:KOSCIUSKO
Mailing Address - State:MS
Mailing Address - Zip Code:39090-3719
Mailing Address - Country:US
Mailing Address - Phone:662-289-7676
Mailing Address - Fax:
Practice Address - Street 1:301 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090
Practice Address - Country:US
Practice Address - Phone:662-289-7676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS45383910311ZA0620X
MS347C00000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No385H00000XRespite Care FacilityRespite Care