Provider Demographics
NPI:1235547878
Name:CHOCTAW REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:CHOCTAW REGIONAL MEDICAL CENTER
Other - Org Name:CHOCTAW MEDICAL CLINIC OF ACKERMAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLINGSWORTH WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-285-9460
Mailing Address - Street 1:8613 MS HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:ACKERMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39735-8917
Mailing Address - Country:US
Mailing Address - Phone:662-285-9460
Mailing Address - Fax:
Practice Address - Street 1:64 N LOUISVILLE ST
Practice Address - Street 2:
Practice Address - City:ACKERMAN
Practice Address - State:MS
Practice Address - Zip Code:39735-9217
Practice Address - Country:US
Practice Address - Phone:662-285-9050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-28
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health