1598324311 NPI number — PINE RIDGE TREATMENT CENTER, INC

Table of content: (NPI 1598324311)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598324311 NPI number — PINE RIDGE TREATMENT CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINE RIDGE TREATMENT CENTER, 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:
1598324311
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P O BOX 959
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUCERNE VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92356-0959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-246-9199
Provider Business Mailing Address Fax Number:
780-248-8479

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9401 CRYSTAL CREEK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUCERNE VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92356-0859
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-248-9199
Provider Business Practice Location Address Fax Number:
780-248-6479
Provider Enumeration Date:
06/06/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GILES
Authorized Official First Name:
WALTER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
909-867-4404

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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