Provider Demographics
NPI:1467672535
Name:COUNTRY PINES INC
Entity Type:Organization
Organization Name:COUNTRY PINES INC
Other - Org Name:COUNTRY PINES GC
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SAULS
Authorized Official - Suffix:SR
Authorized Official - Credentials:BS BUSINESS
Authorized Official - Phone:919-778-4009
Mailing Address - Street 1:2307 N BESTON RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:NC
Mailing Address - Zip Code:28551-8627
Mailing Address - Country:US
Mailing Address - Phone:919-778-4009
Mailing Address - Fax:919-778-4009
Practice Address - Street 1:2308 OAKDALE RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:NC
Practice Address - Zip Code:28551-8627
Practice Address - Country:US
Practice Address - Phone:252-747-4868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL040014320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804005Medicaid