Healthcare Provider Details

I. General information

NPI: 1003128182
Provider Name (Legal Business Name): PINELANDS GROUP HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 07/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E LUKE AVE
SUMMERVILLE SC
29483-6834
US

IV. Provider business mailing address

201 E LUKE AVE
SUMMERVILLE SC
29483-6834
US

V. Phone/Fax

Practice location:
  • Phone: 843-851-0079
  • Fax: 843-873-1002
Mailing address:
  • Phone: 843-851-0079
  • Fax: 843-873-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberSR0008195001CC1
License Number StateSC

VIII. Authorized Official

Name: MS. JOETTE KIZER
Title or Position: CEO
Credential:
Phone: 843-851-0079