Provider Demographics
NPI:1760658587
Name:PINELAND MH/MR/SA CSB
Entity Type:Organization
Organization Name:PINELAND MH/MR/SA CSB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIPOLITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-764-6906
Mailing Address - Street 1:5 W ALTMAN ST
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-5212
Mailing Address - Country:US
Mailing Address - Phone:912-764-6906
Mailing Address - Fax:912-764-3252
Practice Address - Street 1:901 NORTH ST W
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-3503
Practice Address - Country:US
Practice Address - Phone:912-537-9316
Practice Address - Fax:912-537-9915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN068072261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center