Provider Demographics
NPI:1528232915
Name:PINE VILLAGE TREATMENT SERVICES, INC.
Entity Type:Organization
Organization Name:PINE VILLAGE TREATMENT SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEREPENTIGNY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-864-7004
Mailing Address - Street 1:1206 HOPE MILLS RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4215
Mailing Address - Country:US
Mailing Address - Phone:910-864-7004
Mailing Address - Fax:910-864-3002
Practice Address - Street 1:1206 HOPE MILLS RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4215
Practice Address - Country:US
Practice Address - Phone:910-864-7004
Practice Address - Fax:910-864-3002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-047-096101YM0800X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006308Medicaid