Provider Demographics
NPI:1952557365
Name:PINE CASTLE INC.
Entity Type:Organization
Organization Name:PINE CASTLE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:MAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-733-2650
Mailing Address - Street 1:4911 SPRING PARK RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-7456
Mailing Address - Country:US
Mailing Address - Phone:904-733-2650
Mailing Address - Fax:904-733-2681
Practice Address - Street 1:4911 SPRING PARK RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-7456
Practice Address - Country:US
Practice Address - Phone:904-733-2650
Practice Address - Fax:904-733-2681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023-967479Medicaid
FL023-967496Medicaid
FL023-967498Medicaid