Provider Demographics
NPI:1134481674
Name:PIONEER HEALTH SERVICES OF STOKES COUNTY, INC.
Entity Type:Organization
Organization Name:PIONEER HEALTH SERVICES OF STOKES COUNTY, INC.
Other - Org Name:PIONEER FAMILY MEDICAL OF WALNUT COVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCNULTY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:601-849-6440
Mailing Address - Street 1:110 PIONEER WAY
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-5501
Mailing Address - Country:US
Mailing Address - Phone:601-849-6440
Mailing Address - Fax:601-849-1318
Practice Address - Street 1:1072 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT COVE
Practice Address - State:NC
Practice Address - Zip Code:27052-9312
Practice Address - Country:US
Practice Address - Phone:336-591-7001
Practice Address - Fax:336-591-7007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-11
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH1065261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty