Basic Information
| Provider Information | |||||||||
| NPI: | 1295939411 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIEDMONT PIONEER HOUSE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 910 ROBERTS DR | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280545804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048668751 | ||||||||
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| Practice Location | |||||||||
| Address1: | 910 ROBERTS DR | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280545804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048668751 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BURTON | ||||||||
| AuthorizedOfficialFirstName: | VONDA | ||||||||
| AuthorizedOfficialMiddleName: | KAYE | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7048842701 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | QMHP, QDDP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | MHL-036-004 | NC | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
ID Information
| ID | Type | State | Issuer | Description | 8301292S | 05 | NC | MEDICAID |