Provider Demographics
NPI:1104976356
Name:PINE LANE ESTATES LLC
Entity type:Organization
Organization Name:PINE LANE ESTATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:LOECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-665-7255
Mailing Address - Street 1:2905 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078
Mailing Address - Country:US
Mailing Address - Phone:605-665-7255
Mailing Address - Fax:605-668-2800
Practice Address - Street 1:2905 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078
Practice Address - Country:US
Practice Address - Phone:605-665-7255
Practice Address - Fax:605-668-2730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD46906310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9571690Medicaid