Provider Demographics
NPI:1992982805
Name:GREENE RURAL HEALTH CENTER
Entity type:Organization
Organization Name:GREENE RURAL HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ODESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-394-4135
Mailing Address - Street 1:1017 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:LEAKESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39451-9105
Mailing Address - Country:US
Mailing Address - Phone:601-394-4135
Mailing Address - Fax:601-394-4455
Practice Address - Street 1:1017 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:LEAKESVILLE
Practice Address - State:MS
Practice Address - Zip Code:39451-9105
Practice Address - Country:US
Practice Address - Phone:601-394-4135
Practice Address - Fax:601-394-4455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-23
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11343261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02255270Medicaid
MS04428516Medicaid
MS06200741Medicaid
MS251329Medicare Oscar/Certification