Provider Demographics
NPI:1548373665
Name:PONTOTOC LTC, INC
Entity type:Organization
Organization Name:PONTOTOC LTC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:BENNETT
Authorized Official - Last Name:HUBBARD
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:601-849-2294
Mailing Address - Street 1:278 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PONTOTOC
Mailing Address - State:MS
Mailing Address - Zip Code:38863-3612
Mailing Address - Country:US
Mailing Address - Phone:662-489-6411
Mailing Address - Fax:662-489-8498
Practice Address - Street 1:278 W 8TH ST
Practice Address - Street 2:
Practice Address - City:PONTOTOC
Practice Address - State:MS
Practice Address - Zip Code:38863-3612
Practice Address - Country:US
Practice Address - Phone:662-489-6411
Practice Address - Fax:662-489-8498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS305314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230077Medicaid
MS00230077Medicaid