Provider Demographics
NPI:1053072470
Name:PINE GROVE OPCO LLC
Entity Type:Organization
Organization Name:PINE GROVE OPCO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SINGLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-438-3011
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:SC
Mailing Address - Zip Code:29045-0100
Mailing Address - Country:US
Mailing Address - Phone:803-438-3011
Mailing Address - Fax:
Practice Address - Street 1:1500 CHESTNUT RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:SC
Practice Address - Zip Code:29045-9022
Practice Address - Country:US
Practice Address - Phone:803-438-3011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINE GROVE OPCO LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities