Provider Demographics
NPI:1740683671
Name:PINE GROVE ADULT HOME& CARE, INC
Entity type:Organization
Organization Name:PINE GROVE ADULT HOME& CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-531-1008
Mailing Address - Street 1:2609 NORTH GARDEN LANE
Mailing Address - Street 2:
Mailing Address - City:NOTH GARDEN
Mailing Address - State:VA
Mailing Address - Zip Code:22959
Mailing Address - Country:US
Mailing Address - Phone:434-295-4408
Mailing Address - Fax:434-295-1185
Practice Address - Street 1:2609 NORTH GARDEN LANE
Practice Address - Street 2:
Practice Address - City:NOTH GARDEN
Practice Address - State:VA
Practice Address - Zip Code:22959
Practice Address - Country:US
Practice Address - Phone:434-295-4408
Practice Address - Fax:434-295-1185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAALF1078422261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health