Provider Demographics
NPI:1598324311
Name:PINE RIDGE TREATMENT CENTER, INC
Entity Type:Organization
Organization Name:PINE RIDGE TREATMENT CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:GILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-867-4404
Mailing Address - Street 1:P O BOX 959
Mailing Address - Street 2:
Mailing Address - City:LUCERNE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92356-0959
Mailing Address - Country:US
Mailing Address - Phone:760-246-9199
Mailing Address - Fax:780-248-8479
Practice Address - Street 1:9401 CRYSTAL CREEK RD
Practice Address - Street 2:
Practice Address - City:LUCERNE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92356-0859
Practice Address - Country:US
Practice Address - Phone:760-248-9199
Practice Address - Fax:780-248-6479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility