Basic Information
| Provider Information | |||||||||
| NPI: | 1760780969 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMPHIS HEALTH CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 E EH CRUMP BLVD | ||||||||
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| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381265310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012612002 | ||||||||
| FaxNumber: | 9019469262 | ||||||||
| Practice Location | |||||||||
| Address1: | 4940 HIGHWAY 57 | ||||||||
| Address2: | |||||||||
| City: | ROSSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380665068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012617303 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2011 | ||||||||
| LastUpdateDate: | 06/30/2014 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | DOROTHETTE | ||||||||
| AuthorizedOfficialMiddleName: | YVONNE | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9012612025 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEMPHIS HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.