MEDICARE: PINE LEAF INVESTMENT INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	1-134-1797	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033123682
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE LEAF INVESTMENT INC.

Provider Business Mailing Address
First Line	:	PO BOX 179
Second Line	:
City	:	MC RAE
State	:	GA
Zip	:	31055-0179
Country	:	US
Telephone Number	:	229-868-6473
Fax Number	:	229-868-2981

Provider Business Practice Location Address
First Line	:	160 S FIRST AVE
Second Line	:
City	:	MC RAE
State	:	GA
Zip	:	31055-3334
Country	:	US
Telephone Number	:	229-868-6473
Fax Number	:	229-868-2981

Authorized Official
Title or Position	:	COO
Name	:	TERRELL BUFORD COOK
Credential	:
Telephone Number	:	229-868-7406

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	05/19/2013

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