Provider Demographics
NPI:1013189786
Name:PINEHAVEN HOME HEALTH CARE SERVICES INC
Entity Type:Organization
Organization Name:PINEHAVEN HOME HEALTH CARE SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:L
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:252-523-1123
Practice Address - Street 1:2625 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-1459
Practice Address - Country:US
Practice Address - Phone:252-355-1001
Practice Address - Fax:252-355-2205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6600841Medicaid