Provider Demographics
NPI:1598980096
Name:PINECREST DEVELOPMENTAL CENTER
Entity Type:Organization
Organization Name:PINECREST DEVELOPMENTAL CENTER
Other - Org Name:CHARLES PARK COMMUNITY HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MR DD REGIONAL ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:A
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-641-2003
Mailing Address - Street 1:PO BOX 5191
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71361-5191
Mailing Address - Country:US
Mailing Address - Phone:318-442-4655
Mailing Address - Fax:318-641-2309
Practice Address - Street 1:528 BOB WHITE LN
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-2415
Practice Address - Country:US
Practice Address - Phone:318-442-4655
Practice Address - Fax:318-641-2309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA949320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1712337Medicaid