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General NPI Number Information
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NPI Number | 1437163912
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Entity Type | Organization
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Legal Business Name | PINE LEAF INVESTMENT INC.
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Dates
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Enumeration Date | 07/28/2006
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Last Update Date | 05/19/2013
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Provider Practice Location Address
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Address Line | 125 QUIET OAKS DRIVE
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City | CRAWFORD
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State | GA
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Zip | 30630
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Country | US
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Telephone | 706-743-5452
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Fax | 706-743-5655
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Provider Business Mailing Address
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Address Line | 125 QUIET OAKS DRIVE
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City | CRAWFORD
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State | GA
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Zip | 30630
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Country | US
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Telephone | 706-743-5452
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Fax | 706-743-5655
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Authorized Official
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Title or Position | COO
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Name | TERRELL BUFORD COOK
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Credential |
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Telephone | 229-868-7406
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 1-109-173
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License Number State | GA
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