Healthcare Provider Details

I. General information

NPI: 1285056994
Provider Name (Legal Business Name): PINE MOUNTAIN NURSING HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2014
Last Update Date: 12/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 10TH ST
ARCATA CA
95521-6210
US

IV. Provider business mailing address

16233 ASKIN DR. SUITE A
FRAZIER PARK CA
93222-6536
US

V. Phone/Fax

Practice location:
  • Phone: 707-826-8633
  • Fax:
Mailing address:
  • Phone: 661-242-2592
  • Fax: 661-262-7031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberC3624118
License Number StateCA

VIII. Authorized Official

Name: MRS. SHARON M POWELL
Title or Position: OWNER
Credential: FNP-C
Phone: 661-242-2592