Provider Demographics
NPI:1801037957
Name:PINE LAKE BEHAVIORAL SERVICES
Entity Type:Organization
Organization Name:PINE LAKE BEHAVIORAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMAHON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-298-6263
Mailing Address - Street 1:PO BOX 1502
Mailing Address - Street 2:
Mailing Address - City:PINE LAKE
Mailing Address - State:GA
Mailing Address - Zip Code:30072-1502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:433 HEMLOCK DRIVE
Practice Address - Street 2:
Practice Address - City:PINE LAKE
Practice Address - State:GA
Practice Address - Zip Code:30072
Practice Address - Country:US
Practice Address - Phone:404-298-6263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-19
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health