Provider Demographics
NPI:1497968762
Name:COUNTRY PINES INC
Entity Type:Organization
Organization Name:COUNTRY PINES INC
Other - Org Name:COUNTRY PINES #1
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:LA GRANGE
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 1:2307 N BESTON 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:919-778-4009
Practice Address - Fax:919-778-4009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL096117320600000X, 320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804027Medicaid
NC3409221OtherCAP
NC8301207OtherCOMM SUPPORT