Organization
IMANI FAMILY MEDICAL CLINIC, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
NKEBA I BELL FNP (OWNER)
(601) 421-7242
Entity
Organization
Contact information
Practice address
4510 HANGING MOSS RD, JACKSON, MS 39206-3962
(769) 257-5713
(769) 257-5715
Mailing address
4510 HANGING MOSS RD, JACKSON, MS 39206-3962
Taxonomy
Speciality
Code
Description
License number
State
261QP2300X
Primary Care Clinic/Center
Primary
R803867
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00117713
—
MS
01
—
501534
MEDICARE PTAN
—
Enumeration date
01/07/2016
Last updated
10/27/2016
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