Provider Demographics
NPI:1346307899
Name:PINE GROVE INC.
Entity Type:Organization
Organization Name:PINE GROVE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:MOEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-438-3011
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:SC
Mailing Address - Zip Code:29045-0100
Mailing Address - Country:US
Mailing Address - Phone:803-438-3011
Mailing Address - Fax:803-438-8611
Practice Address - Street 1:1500 CHESTNUT ROAD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:SC
Practice Address - Zip Code:29045-0100
Practice Address - Country:US
Practice Address - Phone:803-438-3011
Practice Address - Fax:803-438-8611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSR0008132001CCI322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC961MXHMedicaid