Provider Demographics
NPI:1700983913
Name:PICAYUNE RURAL HEALTH CLINIC
Entity type:Organization
Organization Name:PICAYUNE RURAL HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:HODGE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:601-799-5577
Mailing Address - Street 1:317 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3313
Mailing Address - Country:US
Mailing Address - Phone:601-799-5577
Mailing Address - Fax:601-799-5444
Practice Address - Street 1:317 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3313
Practice Address - Country:US
Practice Address - Phone:601-799-5577
Practice Address - Fax:601-799-5444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13678207R00000X
MSR767181363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09045721Medicaid
MS09045721Medicaid