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General NPI Number Information
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NPI Number | 1104976356
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Entity Type | Organization
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Legal Business Name | PINE LANE ESTATES LLC
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Dates
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Enumeration Date | 01/11/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2905 DOUGLAS AVE
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City | YANKTON
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State | SD
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Zip | 57078
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Country | US
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Telephone | 605-665-7255
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Fax | 605-668-2730
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Provider Business Mailing Address
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Address Line | 2905 DOUGLAS AVE
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City | YANKTON
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State | SD
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Zip | 57078
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Country | US
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Telephone | 605-665-7255
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Fax | 605-668-2800
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. DEANNA JO LOECKER
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Credential |
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Telephone | 605-665-7255
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 46906
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License Number State | SD
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