MEDICARE: PINEHAVEN, 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	310400000X	Assisted Living Facility	11046	SD

General Provider Information

NPI Number	:	1336287911
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINEHAVEN, INC

Provider Business Mailing Address
First Line	:	24102 JACOB MACA RD
Second Line	:
City	:	HILL CITY
State	:	SD
Zip	:	57745-6547
Country	:	US
Telephone Number	:	605-574-4838
Fax Number	:

Provider Business Practice Location Address
First Line	:	23776 PINE HAVEN DR
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-7407
Country	:	US
Telephone Number	:	605-348-2145
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JAMES E. SLICHTER
Credential	:
Telephone Number	:	605-574-4838

Provider Enumeration Date	:	02/03/2007
Last Update Date	:	08/22/2020

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