MEDICARE: PINE RIDGE TREATMENT CENTERS, 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	324500000X	Substance Abuse Rehabilitation Facility	20A3971	CA

General Provider Information

NPI Number	:	1508903683
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE RIDGE TREATMENT CENTERS, INC.

Provider Business Mailing Address
First Line	:	PO BOX 2303
Second Line	:
City	:	RUNNING SPRINGS
State	:	CA
Zip	:	92382-2303
Country	:	US
Telephone Number	:	909-867-7027
Fax Number	:

Provider Business Practice Location Address
First Line	:	2727 HIGHLAND DR
Second Line	:
City	:	RUNNING SPRINGS
State	:	CA
Zip	:	92382-2303
Country	:	US
Telephone Number	:	909-867-7027
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	WALTER GILES
Credential	:
Telephone Number	:	909-867-4404

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	02/24/2009

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