Provider Demographics
NPI:1053439133
Name:MALLORY COMMUNITY HEALTH
Entity type:Organization
Organization Name:MALLORY COMMUNITY HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INTERIM CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEWERY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-834-1857
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:VAIDEN
Mailing Address - State:MS
Mailing Address - Zip Code:39176-0369
Mailing Address - Country:US
Mailing Address - Phone:662-464-5470
Mailing Address - Fax:662-464-0152
Practice Address - Street 1:201A MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:VAIDEN
Practice Address - State:MS
Practice Address - Zip Code:39176-5644
Practice Address - Country:US
Practice Address - Phone:662-464-5470
Practice Address - Fax:662-464-0152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS251880Medicare Oscar/Certification