Provider Demographics
NPI:1992284483
Name:PINE SHADOWS RETIREMENT MANOR
Entity type:Organization
Organization Name:PINE SHADOWS RETIREMENT MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:229-776-7565
Mailing Address - Street 1:202 E BRYANT DR
Mailing Address - Street 2:
Mailing Address - City:SYLVESTER
Mailing Address - State:GA
Mailing Address - Zip Code:31791-7350
Mailing Address - Country:US
Mailing Address - Phone:229-776-7565
Mailing Address - Fax:229-776-1855
Practice Address - Street 1:202 E BRYANT DR
Practice Address - Street 2:
Practice Address - City:SYLVESTER
Practice Address - State:GA
Practice Address - Zip Code:31791-7350
Practice Address - Country:US
Practice Address - Phone:229-776-7565
Practice Address - Fax:229-776-1855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility