Provider Demographics
NPI:1902020662
Name:PINE FORREST FARM INC
Entity type:Organization
Organization Name:PINE FORREST FARM INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EMANUEL
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:BONAPARTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-615-7030
Mailing Address - Street 1:4190 NC HIGHWAY 801 N
Mailing Address - Street 2:
Mailing Address - City:MOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27028-6234
Mailing Address - Country:US
Mailing Address - Phone:336-998-3480
Mailing Address - Fax:336-998-0177
Practice Address - Street 1:4190 NC HIGHWAY 801 N
Practice Address - Street 2:
Practice Address - City:MOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27028-6234
Practice Address - Country:US
Practice Address - Phone:336-998-3480
Practice Address - Fax:336-998-0177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL030028322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children