1609053727 NPI number — PINECREST SUPPORTS AND SERVICES CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609053727 NPI number — PINECREST SUPPORTS AND SERVICES CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINECREST SUPPORTS AND SERVICES CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OAK RUN COMMUNITY HOME
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609053727
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P. O. BOX 5191
Provider Second Line Business Mailing Address:
ATTENTION: QMI
Provider Business Mailing Address City Name:
PINEVILLE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71361-5191
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-641-2000
Provider Business Mailing Address Fax Number:
318-641-2309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
224 ROBERTSON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALL
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71405-3863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-640-3955
Provider Business Practice Location Address Fax Number:
318-640-3955
Provider Enumeration Date:
01/31/2008

Additional Information

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
SHERRI
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MR DD REGIONAL ADMINISTRATOR
Authorized Official Telephone Number:
318-641-2003

Provider Taxonomy Codes

  • Taxonomy code: 320900000X , with the licence number:  1023 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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