Provider Demographics
NPI:1851582597
Name:PINE CREST VILLAGE LLC
Entity Type:Organization
Organization Name:PINE CREST VILLAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILITY MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-746-1280
Mailing Address - Street 1:1241 N 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-3535
Mailing Address - Country:US
Mailing Address - Phone:920-746-1280
Mailing Address - Fax:920-746-9404
Practice Address - Street 1:1241 N 18TH AVE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-3535
Practice Address - Country:US
Practice Address - Phone:920-746-1280
Practice Address - Fax:920-746-9404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10344310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility