Provider Demographics
NPI:1134116825
Name:PINECREST LLC
Entity Type:Organization
Organization Name:PINECREST LLC
Other - Org Name:PINECREST GUEST HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:RON
Authorized Official - Last Name:GUINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-686-0040
Mailing Address - Street 1:133 PINE ST
Mailing Address - Street 2:
Mailing Address - City:HAZLEHURST
Mailing Address - State:MS
Mailing Address - Zip Code:39083-2309
Mailing Address - Country:US
Mailing Address - Phone:601-894-1411
Mailing Address - Fax:601-894-3282
Practice Address - Street 1:133 PINE ST
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:MS
Practice Address - Zip Code:39083-2309
Practice Address - Country:US
Practice Address - Phone:601-894-1411
Practice Address - Fax:601-894-3282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS366314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00230140Medicaid
MS00230140Medicaid