Healthcare Provider Details

I. General information

NPI: 1073920328
Provider Name (Legal Business Name): PONTOTOC HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2014
Last Update Date: 09/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 COUNTRY CLUB RD
HOUSTON MS
38851-9326
US

IV. Provider business mailing address

176 S MAIN ST
PONTOTOC MS
38863-3311
US

V. Phone/Fax

Practice location:
  • Phone: 662-456-3437
  • Fax:
Mailing address:
  • Phone: 662-489-5510
  • 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. JOSEPH A REPPERT
Title or Position: CFO
Credential:
Phone: 662-377-3978