Provider Demographics
NPI:1164544110
Name:HICKORY PINE ASSOCIATES
Entity Type:Organization
Organization Name:HICKORY PINE ASSOCIATES
Other - Org Name:HICKORY HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:EXEC DIR OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:TRINIDAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-484-1115
Mailing Address - Street 1:PO BOX 3141
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93011-3141
Mailing Address - Country:US
Mailing Address - Phone:805-484-1115
Mailing Address - Fax:508-484-9038
Practice Address - Street 1:50 OAK ST
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-7922
Practice Address - Country:US
Practice Address - Phone:805-484-1115
Practice Address - Fax:805-484-9038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility