Provider Demographics
NPI:1477650752
Name:PINEWOOD RETIREMENT VILLA, INC.
Entity Type:Organization
Organization Name:PINEWOOD RETIREMENT VILLA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:CRUMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-783-1623
Mailing Address - Street 1:2 SLAPPEY DR
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036-1459
Mailing Address - Country:US
Mailing Address - Phone:478-783-1623
Mailing Address - Fax:478-783-3432
Practice Address - Street 1:2 SLAPPEY DR
Practice Address - Street 2:
Practice Address - City:HAWKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31036-1459
Practice Address - Country:US
Practice Address - Phone:478-783-1623
Practice Address - Fax:478-783-3432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00594305AMedicaid