Provider Demographics
NPI:1386952141
Name:PIONEER HEALTH SERVICES OF EARLY COUNTY, LLC
Entity type:Organization
Organization Name:PIONEER HEALTH SERVICES OF EARLY COUNTY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCNULTY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:601-849-6440
Mailing Address - Street 1:11740 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:BLAKELY
Mailing Address - State:GA
Mailing Address - Zip Code:39823-2574
Mailing Address - Country:US
Mailing Address - Phone:229-723-3795
Mailing Address - Fax:229-723-8024
Practice Address - Street 1:11740 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:GA
Practice Address - Zip Code:39823-2574
Practice Address - Country:US
Practice Address - Phone:229-723-3795
Practice Address - Fax:229-723-8024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049-667314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA049-667OtherLICENSE
GA00140873AMedicaid
GA115271Medicare Oscar/Certification