Provider Demographics
NPI:1972729747
Name:PINE HAVEN BOYS CENTER, INC.
Entity Type:Organization
Organization Name:PINE HAVEN BOYS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:VITALI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-485-7141
Mailing Address - Street 1:133 RIVER RD
Mailing Address - Street 2:PO BOX 162
Mailing Address - City:ALLENSTOWN
Mailing Address - State:NH
Mailing Address - Zip Code:03275-2362
Mailing Address - Country:US
Mailing Address - Phone:603-485-7141
Mailing Address - Fax:603-485-7142
Practice Address - Street 1:133 RIVER RD
Practice Address - Street 2:
Practice Address - City:ALLENSTOWN
Practice Address - State:NH
Practice Address - Zip Code:03275-2362
Practice Address - Country:US
Practice Address - Phone:603-485-7141
Practice Address - Fax:603-485-7142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1073322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30007076Medicaid