Provider Demographics
NPI:1740330026
Name:PINNACLE HOMES DDA LLC
Entity type:Organization
Organization Name:PINNACLE HOMES DDA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ELLIS
Authorized Official - Middle Name:REID
Authorized Official - Last Name:FOREST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-368-2778
Mailing Address - Street 1:1169 PERCH RD
Mailing Address - Street 2:PO BOX 70
Mailing Address - City:PINNACLE
Mailing Address - State:NC
Mailing Address - Zip Code:27043-8312
Mailing Address - Country:US
Mailing Address - Phone:366-368-2778
Mailing Address - Fax:336-368-2779
Practice Address - Street 1:1169 PERCH RD
Practice Address - Street 2:
Practice Address - City:PINNACLE
Practice Address - State:NC
Practice Address - Zip Code:27043-8312
Practice Address - Country:US
Practice Address - Phone:366-368-2778
Practice Address - Fax:336-368-2779
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
NCMHL085026320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301629Medicaid