Provider Demographics
NPI:1184769317
Name:PINEBROOK RESIDENTIAL CENTER 1
Entity type:Organization
Organization Name:PINEBROOK RESIDENTIAL CENTER 1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:H
Authorized Official - Last Name:LEONARD
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC, NC LIC ADM
Authorized Official - Phone:828-655-3222
Mailing Address - Street 1:PO BOX 760
Mailing Address - Street 2:
Mailing Address - City:YADKINVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27055-0760
Mailing Address - Country:US
Mailing Address - Phone:828-655-3222
Mailing Address - Fax:336-679-7500
Practice Address - Street 1:312 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:YADKINVILLE
Practice Address - State:NC
Practice Address - Zip Code:27055-8247
Practice Address - Country:US
Practice Address - Phone:828-655-3222
Practice Address - Fax:336-679-7500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-099-009311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home