Provider Demographics
NPI:1730461211
Name:PIONEER HEALTH SERVICES OF CHOCTAW COUNTY, LLC
Entity Type:Organization
Organization Name:PIONEER HEALTH SERVICES OF CHOCTAW COUNTY, LLC
Other - Org Name:PIONEER FAMILY MEDICAL OF WEIR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
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:662-547-9407
Mailing Address - Street 1:780 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WEIR
Mailing Address - State:MS
Mailing Address - Zip Code:39772-0000
Mailing Address - Country:US
Mailing Address - Phone:662-547-9407
Mailing Address - Fax:662-547-9408
Practice Address - Street 1:780 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WEIR
Practice Address - State:MS
Practice Address - Zip Code:39772-0000
Practice Address - Country:US
Practice Address - Phone:662-547-9407
Practice Address - Fax:662-547-9408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-12
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center