=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982739488
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINE VALLEY ADULT CARE HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3522 CAMDEN RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28306-7717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-425-8954
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 35534
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28303-0534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTATOR
-----------------------------------------------------
Name | ARETTA ROBINSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-527-9898
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320700000X
-----------------------------------------------------
Taxonomy Name | Physical Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | HAL 026048
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------