Provider Demographics
NPI:1174852875
Name:PINECREST DEVELOPMENTAL CENTER
Entity Type:Organization
Organization Name:PINECREST DEVELOPMENTAL CENTER
Other - Org Name:PINECREST DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MR/DD REGIONAL ASSOC. ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAXTON
Authorized Official - Middle Name:E
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:II
Authorized Official - Credentials:MS
Authorized Official - Phone:318-487-5395
Mailing Address - Street 1:PO BOX 5191
Mailing Address - Street 2:ATTN; PAXTON OLIVER
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71361-5191
Mailing Address - Country:US
Mailing Address - Phone:318-487-5395
Mailing Address - Fax:318-487-5463
Practice Address - Street 1:100 PINECREST DR
Practice Address - Street 2:ATTN: PAXTON OLIVER
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4276
Practice Address - Country:US
Practice Address - Phone:318-487-5395
Practice Address - Fax:318-487-5463
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PINECREST DEVELOPMENTAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-09
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental