Provider Demographics
NPI:1376849174
Name:PINECREST CARE CENTER LLC
Entity Type:Organization
Organization Name:PINECREST CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-296-5105
Mailing Address - Street 1:500 N MARKET PLACE DR
Mailing Address - Street 2:SUITE 203
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-1708
Mailing Address - Country:US
Mailing Address - Phone:801-296-5105
Mailing Address - Fax:801-382-1098
Practice Address - Street 1:1020 PINE ST
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:KS
Practice Address - Zip Code:66748-1960
Practice Address - Country:US
Practice Address - Phone:620-473-2393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DNR TWO, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-27
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility