Provider Demographics
NPI:1235697483
Name:PINE LEAF PERSONAL CARE HOME
Entity Type:Organization
Organization Name:PINE LEAF PERSONAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHOMANKIA
Authorized Official - Middle Name:PINKSTON
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-575-0083
Mailing Address - Street 1:121 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:EAST DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31027-7778
Mailing Address - Country:US
Mailing Address - Phone:478-575-0083
Mailing Address - Fax:
Practice Address - Street 1:121 S ELM ST
Practice Address - Street 2:
Practice Address - City:EAST DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31027-7778
Practice Address - Country:US
Practice Address - Phone:478-575-0083
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA3155885Medicaid