Provider Demographics
NPI:1659580470
Name:PINE ACRE FAMILY CARE HOME #2
Entity Type:Organization
Organization Name:PINE ACRE FAMILY CARE HOME #2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:HAROLD
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:SR
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:910-592-1950
Mailing Address - Street 1:156 PINE ACRES LN
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-7390
Mailing Address - Country:US
Mailing Address - Phone:910-592-1950
Mailing Address - Fax:910-592-8880
Practice Address - Street 1:156 PINE ACRES LN
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-7390
Practice Address - Country:US
Practice Address - Phone:910-592-1950
Practice Address - Fax:910-592-8880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-082-010311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7803992Medicaid