Healthcare Provider Details

I. General information

NPI: 1033123682
Provider Name (Legal Business Name): PINE LEAF INVESTMENT INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 05/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 S FIRST AVE
MC RAE GA
31055-3334
US

IV. Provider business mailing address

PO BOX 179
MC RAE GA
31055-0179
US

V. Phone/Fax

Practice location:
  • Phone: 229-868-6473
  • Fax: 229-868-2981
Mailing address:
  • Phone: 229-868-6473
  • Fax: 229-868-2981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1-134-1797
License Number StateGA

VIII. Authorized Official

Name: TERRELL BUFORD COOK
Title or Position: COO
Credential:
Phone: 229-868-7406