MEDICARE: PINE GROVE GROUP HOME, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174200000X	Meals Provider
2	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	069801001	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0269801001	OTHER	VA	PROVIDER
2	0269801001	OTHER		PROVIDER

General Provider Information

NPI Number	:	1922519826
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE GROVE GROUP HOME, LLC

Provider Business Mailing Address
First Line	:	4116 RED HILL SCHOOL RD
Second Line	:
City	:	NORTH GARDEN
State	:	VA
Zip	:	22959-1733
Country	:	US
Telephone Number	:	434-295-1615
Fax Number	:

Provider Business Practice Location Address
First Line	:	4116 RED HILL SCHOOL RD
Second Line	:
City	:	NORTH GARDEN
State	:	VA
Zip	:	22959-1733
Country	:	US
Telephone Number	:	434-295-1615
Fax Number	:

Authorized Official
Title or Position	:	DEPUTY DIRECTOR
Name	:	MRS. STEPHANIE JANE JONES
Credential	:	RMA
Telephone Number	:	434-981-4052

Provider Enumeration Date	:	10/18/2017
Last Update Date	:	06/16/2018

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