Healthcare Provider Details

I. General information

NPI: 1053728139
Provider Name (Legal Business Name): PONTOTOC HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 MAIN ST
ECRU MS
38841-9604
US

IV. Provider business mailing address

202 MAIN ST
ECRU MS
38841-9604
US

V. Phone/Fax

Practice location:
  • Phone: 662-489-4345
  • Fax:
Mailing address:
  • Phone: 662-489-4345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number16091
License Number StateMS

VIII. Authorized Official

Name: MR. BRUCE TOPPIN
Title or Position: CORPORATE SECRETARY
Credential:
Phone: 662-377-3000