1437163912 NPI number — PINE LEAF INVESTMENT INC.

Table of content: (NPI 1437163912)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437163912 NPI number — PINE LEAF INVESTMENT INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINE LEAF INVESTMENT INC.
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:
QUIET OAKS HEALTH CARE CENTER
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:
1437163912
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 QUIET OAKS DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRAWFORD
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-743-5452
Provider Business Mailing Address Fax Number:
706-743-5655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 QUIET OAKS DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRAWFORD
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-743-5452
Provider Business Practice Location Address Fax Number:
706-743-5655
Provider Enumeration Date:
07/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COOK
Authorized Official First Name:
TERRELL
Authorized Official Middle Name:
BUFORD
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
229-868-7406

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  1-109-173 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000370851A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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