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General NPI Number Information
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NPI Number | 1184769317
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Entity Type | Organization
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Legal Business Name | PINEBROOK RESIDENTIAL CENTER 1
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Dates
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Enumeration Date | 02/21/2007
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Last Update Date | 05/06/2016
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Provider Practice Location Address
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Address Line | 312 HARRISON AVE
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City | YADKINVILLE
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State | NC
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Zip | 27055-8247
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Country | US
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Telephone | 828-655-3222
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Fax | 336-679-7500
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Provider Business Mailing Address
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Address Line | PO BOX 760
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City | YADKINVILLE
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State | NC
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Zip | 27055-0760
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Country | US
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Telephone | 828-655-3222
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Fax | 336-679-7500
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. FRED H. LEONARD
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Credential | MS, LPC, NC LIC. ADM
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Telephone | 828-655-3222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | HAL-099-009
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License Number State | NC
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