Healthcare Provider Details

I. General information

NPI: 1386952141
Provider Name (Legal Business Name): PIONEER HEALTH SERVICES OF EARLY COUNTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11740 COLUMBIA ST
BLAKELY GA
39823-2574
US

IV. Provider business mailing address

11740 COLUMBIA ST
BLAKELY GA
39823-2574
US

V. Phone/Fax

Practice location:
  • Phone: 229-723-3795
  • Fax: 229-723-8024
Mailing address:
  • Phone: 229-723-3795
  • Fax: 229-723-8024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number049-667
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier049-667
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerLICENSE
# 2
Identifier00140873A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: MR. JOSEPH S MCNULTY III
Title or Position: CEO
Credential:
Phone: 601-849-6440