Provider Demographics
NPI:1720165434
Name:PINE FOREST HEALTH AND REHAB CENTER, LLC
Entity type:Organization
Organization Name:PINE FOREST HEALTH AND REHAB CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PONTHIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-797-9066
Mailing Address - Street 1:203 N CLIFTON ST
Mailing Address - Street 2:
Mailing Address - City:FORDYCE
Mailing Address - State:AR
Mailing Address - Zip Code:71742-3026
Mailing Address - Country:US
Mailing Address - Phone:870-352-3625
Mailing Address - Fax:870-352-5053
Practice Address - Street 1:203 N CLIFTON ST
Practice Address - Street 2:
Practice Address - City:FORDYCE
Practice Address - State:AR
Practice Address - Zip Code:71742-3026
Practice Address - Country:US
Practice Address - Phone:870-352-3625
Practice Address - Fax:870-352-5053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR825314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility