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NPI Code Detail

MEDICARE: PINEY WOODS ER IV

MEDICARE: PINEY WOODS ER IV
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QE0002XEmergency Care Clinic/Center

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1160260OTHERTXDEPARTMENT OF STATE HEALTH SERVICES

General Provider Information

NPI Number : 1831550664
Entity Type Code : Organization
Provider Name (Legal Business Name) : PINEY WOODS ER IV
Provider Business Mailing Address
First Line : 1420 NORTH ST
Second Line :
City : NACOGDOCHES
State : TX
Zip : 75961-4037
Country : US
Telephone Number : 936-569-0911
Fax Number : 936-569-9131
Provider Business Practice Location Address
First Line : 1420 NORTH ST
Second Line :
City : NACOGDOCHES
State : TX
Zip : 75961-4037
Country : US
Telephone Number : 936-569-0911
Fax Number :
Authorized Official
Title or Position : CEO
Name : DR. CHRISTOPHER KWON
Credential : MD
Telephone Number : 936-569-0911
Provider Enumeration Date : 03/07/2016
Last Update Date : 09/01/2016

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