Provider Demographics
NPI:1548720568
Name:FIRST CHOICE FAMILY HEALTHCARE CLINIC LLC
Entity type:Organization
Organization Name:FIRST CHOICE FAMILY HEALTHCARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DNP/COO
Authorized Official - Prefix:DR
Authorized Official - First Name:MORLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-C
Authorized Official - Phone:601-526-9001
Mailing Address - Street 1:PO BOX 1473
Mailing Address - Street 2:
Mailing Address - City:RAYMOND
Mailing Address - State:MS
Mailing Address - Zip Code:39154-1473
Mailing Address - Country:US
Mailing Address - Phone:601-526-9001
Mailing Address - Fax:601-526-9118
Practice Address - Street 1:119 S OAK STE 2
Practice Address - Street 2:
Practice Address - City:RAYMOND
Practice Address - State:MS
Practice Address - Zip Code:39154-4205
Practice Address - Country:US
Practice Address - Phone:601-526-9001
Practice Address - Fax:601-526-9118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-25
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1548720568Medicaid