Provider Demographics
NPI:1881974749
Name:PINECREST DEVELOPMENTAL CENTER
Entity type:Organization
Organization Name:PINECREST DEVELOPMENTAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MR/DD REGIONAL ASSOCIATE ADMINISTER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAXTON
Authorized Official - Middle Name:ENIS
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:II
Authorized Official - Credentials:MS
Authorized Official - Phone:318-487-5395
Mailing Address - Street 1:2006 GUS KAPLAN DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-3376
Mailing Address - Country:US
Mailing Address - Phone:318-487-5395
Mailing Address - Fax:318-487-5463
Practice Address - Street 1:2006 GUS KAPLAN DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3376
Practice Address - Country:US
Practice Address - Phone:318-487-5395
Practice Address - Fax:318-487-5463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-24
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA320600000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities