Provider Demographics
NPI:1770705170
Name:SOUTH PIKE
Entity type:Organization
Organization Name:SOUTH PIKE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DISTRICT SUPERINTENDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-783-3742
Mailing Address - Street 1:444 AMITE STREET
Mailing Address - Street 2:
Mailing Address - City:OSYKA
Mailing Address - State:MS
Mailing Address - Zip Code:39657
Mailing Address - Country:US
Mailing Address - Phone:601-542-3354
Mailing Address - Fax:
Practice Address - Street 1:444 AMITE STREET
Practice Address - Street 2:
Practice Address - City:OSYKA
Practice Address - State:MS
Practice Address - Zip Code:39657
Practice Address - Country:US
Practice Address - Phone:601-542-3354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR868937163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WS0200XNursing Service ProvidersRegistered NurseSchoolGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06787291Medicaid