Healthcare Provider Details

I. General information

NPI: 1770705170
Provider Name (Legal Business Name): SOUTH PIKE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 AMITE STREET
OSYKA MS
39657
US

IV. Provider business mailing address

444 AMITE STREET
OSYKA MS
39657
US

V. Phone/Fax

Practice location:
  • Phone: 601-542-3354
  • Fax:
Mailing address:
  • Phone: 601-542-3354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR868937
License Number StateMS

VIII. Authorized Official

Name: DR. BILL GUNNELL
Title or Position: DISTRICT SUPERINTENDENT
Credential:
Phone: 601-783-3742