Provider Demographics
NPI:1205393287
Name:PINE FAMILY INC
Entity Type:Organization
Organization Name:PINE FAMILY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LOU
Authorized Official - Last Name:PINE
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:509-836-2367
Mailing Address - Street 1:203 SW MALIBU DR
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-9419
Mailing Address - Country:US
Mailing Address - Phone:509-836-2367
Mailing Address - Fax:855-784-6425
Practice Address - Street 1:2240 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-2487
Practice Address - Country:US
Practice Address - Phone:509-836-2367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2109936Medicaid