Provider Demographics
NPI:1922519826
Name:PINE GROVE GROUP HOME, LLC
Entity Type:Organization
Organization Name:PINE GROVE GROUP HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:RMA
Authorized Official - Phone:434-981-4052
Mailing Address - Street 1:4116 RED HILL SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:NORTH GARDEN
Mailing Address - State:VA
Mailing Address - Zip Code:22959-1733
Mailing Address - Country:US
Mailing Address - Phone:434-295-1615
Mailing Address - Fax:
Practice Address - Street 1:4116 RED HILL SCHOOL RD
Practice Address - Street 2:
Practice Address - City:NORTH GARDEN
Practice Address - State:VA
Practice Address - Zip Code:22959-1733
Practice Address - Country:US
Practice Address - Phone:434-295-1615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-18
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174200000X
VA069801001320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No174200000XOther Service ProvidersMeals
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0269801001OtherPROVIDER
0269801001OtherPROVIDER