=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629143136
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PIONEER HEALTH SERVICES OF NEWTON COUNTY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2006
-----------------------------------------------------
Last Update Date | 09/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9421 EASTSIDE DRIVE EXTENTION
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-683-0279
-----------------------------------------------------
Fax | 601-683-0264
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9421 EASTSIDE DRIVE EXTENSION
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-683-0279
-----------------------------------------------------
Fax | 601-683-0264
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JOSEPH S MCNULTY III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-849-6440
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 273R00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital Unit
-----------------------------------------------------
License Number | 16-321
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------