Healthcare Provider Details

I. General information

NPI: 1679756324
Provider Name (Legal Business Name): PINECREST DEVELOPMENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 12/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5602 MAR BUD TRACE
PINEVILLE LA
71361
US

IV. Provider business mailing address

PO BOX 5191
PINEVILLE LA
71361-5191
US

V. Phone/Fax

Practice location:
  • Phone: 318-441-9905
  • Fax: 318-441-9905
Mailing address:
  • Phone: 318-641-2000
  • Fax: 318-641-2309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number1612
License Number StateLA

VIII. Authorized Official

Name: MS. SHERRI A EVANS
Title or Position: MR DD REGIONAL ADMINISTRATOR
Credential:
Phone: 318-641-2003