Basic Information
| Provider Information | |||||||||
| NPI: | 1376849174 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINECREST CARE CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 N MARKET PLACE DR | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | CENTERVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840141708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012965105 | ||||||||
| FaxNumber: | 8013821098 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 PINE ST | ||||||||
| Address2: | |||||||||
| City: | HUMBOLDT | ||||||||
| State: | KS | ||||||||
| PostalCode: | 667481960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6204732393 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2011 | ||||||||
| LastUpdateDate: | 01/27/2011 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | SHAUNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8012965105 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DNR TWO, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.