Provider Demographics
NPI:1528242633
Name:PINE FOREST REST, INC
Entity type:Organization
Organization Name:PINE FOREST REST, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:JOHNSON
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:LPN, ADMINISTRATOR
Authorized Official - Phone:252-587-1591
Mailing Address - Street 1:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:POTECASI
Mailing Address - State:NC
Mailing Address - Zip Code:27867-0067
Mailing Address - Country:US
Mailing Address - Phone:252-587-1591
Mailing Address - Fax:252-587-1196
Practice Address - Street 1:3277 NC 35
Practice Address - Street 2:
Practice Address - City:POTECASI
Practice Address - State:NC
Practice Address - Zip Code:27867-0067
Practice Address - Country:US
Practice Address - Phone:252-587-1591
Practice Address - Fax:252-587-1196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-066-001310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility