Provider Demographics
NPI:1194968982
Name:CLAIBORNE COUNTY FAMILY HEALTH CENTER, INC.
Entity type:Organization
Organization Name:CLAIBORNE COUNTY FAMILY HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CONEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-437-3052
Mailing Address - Street 1:PO BOX 741
Mailing Address - Street 2:
Mailing Address - City:PORT GIBSON
Mailing Address - State:MS
Mailing Address - Zip Code:39150-0741
Mailing Address - Country:US
Mailing Address - Phone:601-437-3049
Mailing Address - Fax:601-437-3051
Practice Address - Street 1:2045 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:PORT GIBSON
Practice Address - State:MS
Practice Address - Zip Code:39150-4262
Practice Address - Country:US
Practice Address - Phone:601-437-3049
Practice Address - Fax:601-437-3051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QD0000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013386Medicaid