Healthcare Provider Details

I. General information

NPI: 1669389524
Provider Name (Legal Business Name): PINE LAKE FUND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11825 PINE LAKE RD
PLAINWELL MI
49080-9218
US

IV. Provider business mailing address

11825 PINE LAKE RD
PLAINWELL MI
49080-9218
US

V. Phone/Fax

Practice location:
  • Phone: 269-598-0636
  • Fax:
Mailing address:
  • Phone: 269-598-0636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. TIFFANY BETTY WHITE
Title or Position: EXECUTIVE DIRECTOR
Credential: PHD
Phone: 269-598-0636