Provider Demographics
NPI:1710944087
Name:PINELANDS GROUP HOMES, INC
Entity Type:Organization
Organization Name:PINELANDS GROUP HOMES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JOETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-851-0079
Mailing Address - Street 1:201 E LUKE AVE
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-6834
Mailing Address - Country:US
Mailing Address - Phone:843-851-0079
Mailing Address - Fax:843-873-1002
Practice Address - Street 1:201 E LUKE AVE
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6834
Practice Address - Country:US
Practice Address - Phone:843-851-0079
Practice Address - Fax:843-873-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSR-0008195001-CC1322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC927MXHMedicaid