Provider Demographics
NPI:1093844144
Name:WINSTON COUNTY MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:WINSTON COUNTY MEDICAL FOUNDATION
Other - Org Name:WINSTON MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAULTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-779-5101
Mailing Address - Street 1:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39339-0967
Mailing Address - Country:US
Mailing Address - Phone:662-773-6211
Mailing Address - Fax:662-773-6223
Practice Address - Street 1:562 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:MS
Practice Address - Zip Code:39339-2742
Practice Address - Country:US
Practice Address - Phone:662-773-6211
Practice Address - Fax:662-773-6223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS208314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230020Medicaid