Provider Demographics
NPI:1952614190
Name:PINECREST DEVELOPMENTAL CENTER
Entity Type:Organization
Organization Name:PINECREST DEVELOPMENTAL CENTER
Other - Org Name:CENTRAL LA. BEHAVIORAL/HEALTH RESOURCE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MR/DD REGIONAL ASSOC. ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAXTON
Authorized Official - Middle Name:E
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:II
Authorized Official - Credentials:M S
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?:Yes
Parent Organization LBN:PINECREST DEVELOPMENTAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty