1477650752 NPI number — PINEWOOD RETIREMENT VILLA, INC.

Table of content: MRS. ANISA ANNE MANION CRNA (NPI 1205986999)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477650752 NPI number — PINEWOOD RETIREMENT VILLA, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINEWOOD RETIREMENT VILLA, 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:
Provider Other Organization Name Type Code:
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:
1477650752
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 SLAPPEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAWKINSVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31036-1459
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-783-1623
Provider Business Mailing Address Fax Number:
478-783-3432

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 SLAPPEY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAWKINSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31036-1459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-783-1623
Provider Business Practice Location Address Fax Number:
478-783-3432
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CRUMP
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
GARY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
478-783-1623

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , 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: 00594305A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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