Provider Demographics
NPI:1013182286
Name:PINE VILLAGE TREATMENT SERVICES INC
Entity Type:Organization
Organization Name:PINE VILLAGE TREATMENT SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEREPENTIGNY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-864-7004
Mailing Address - Street 1:106 S LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-2527
Mailing Address - Country:US
Mailing Address - Phone:919-550-7645
Mailing Address - Fax:919-550-7754
Practice Address - Street 1:106 S LOMBARD ST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-2527
Practice Address - Country:US
Practice Address - Phone:919-550-7645
Practice Address - Fax:919-550-7754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006309Medicaid