MEDICARE: PINELAND MH/MR/SA CSB

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	261Q00000X	Clinic/Center	LPN068072	GA

General Provider Information

NPI Number	:	1760658587
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINELAND MH/MR/SA CSB

Provider Business Mailing Address
First Line	:	5 W ALTMAN ST
Second Line	:
City	:	STATESBORO
State	:	GA
Zip	:	30458-5212
Country	:	US
Telephone Number	:	912-764-6906
Fax Number	:	912-764-3252

Provider Business Practice Location Address
First Line	:	901 NORTH ST W
Second Line	:
City	:	VIDALIA
State	:	GA
Zip	:	30474-3503
Country	:	US
Telephone Number	:	912-537-9316
Fax Number	:	912-537-9915

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	JUNE A DIPOLITO
Credential	:
Telephone Number	:	912-764-6906

Provider Enumeration Date	:	05/01/2008
Last Update Date	:	05/01/2008

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