Healthcare Provider Details

I. General information

NPI: 1497968762
Provider Name (Legal Business Name): COUNTRY PINES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2307 N BESTON RD
LA GRANGE NC
28551-8627
US

IV. Provider business mailing address

2307 N BESTON RD
LA GRANGE NC
28551-8627
US

V. Phone/Fax

Practice location:
  • Phone: 919-778-4009
  • Fax: 919-778-4009
Mailing address:
  • Phone: 919-778-4009
  • Fax: 919-778-4009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL096117
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberMHL096117
License Number StateNC

VIII. Authorized Official

Name: MR. KENNETH MICHAEL SAULS SR.
Title or Position: VICE PRESIDENT
Credential: BS BUSINESS
Phone: 919-778-4009