Provider Demographics
NPI:1588735252
Name:PINELAND MHMRSA
Entity type:Organization
Organization Name:PINELAND MHMRSA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DIPOLITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-764-6906
Mailing Address - Street 1:PO BOX 745
Mailing Address - Street 2:5 WEST ALTMAN STREET
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-0745
Mailing Address - Country:US
Mailing Address - Phone:912-764-6906
Mailing Address - Fax:912-764-6466
Practice Address - Street 1:5 W ALTMAN ST
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-5212
Practice Address - Country:US
Practice Address - Phone:912-764-6906
Practice Address - Fax:912-764-6466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2277Medicare ID - Type UnspecifiedAGENCY GROUP NUMBER