Provider Demographics
NPI:1760657282
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:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-354-4794
Mailing Address - Street 1:106 S LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-2527
Mailing Address - Country:US
Mailing Address - Phone:919-550-7645
Mailing Address - Fax:
Practice Address - Street 1:106 S LOMBARD ST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-2527
Practice Address - Country:US
Practice Address - Phone:919-550-7645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302128Medicaid