Provider Demographics
NPI:1003087347
Name:PINE HAVENHOME HEALTH CARE SERVICES INC.
Entity Type:Organization
Organization Name:PINE HAVENHOME HEALTH CARE SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-523-1963
Mailing Address - Street 1:1108 N HERRITAGE ST
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-3834
Mailing Address - Country:US
Mailing Address - Phone:252-523-1963
Mailing Address - Fax:
Practice Address - Street 1:1108 N HERRITAGE ST
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-3834
Practice Address - Country:US
Practice Address - Phone:252-523-1963
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6600841Medicaid