Provider Demographics
NPI:1366949109
Name:PINE GROVE ADULT HOME. INC
Entity type:Organization
Organization Name:PINE GROVE ADULT HOME. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:BACHELOR'S DEGREE
Authorized Official - Phone:434-531-1008
Mailing Address - Street 1:2541 N GARDEN LN
Mailing Address - Street 2:
Mailing Address - City:NORTH GARDEN
Mailing Address - State:VA
Mailing Address - Zip Code:22959-1604
Mailing Address - Country:US
Mailing Address - Phone:434-531-1008
Mailing Address - Fax:434-295-1185
Practice Address - Street 1:2609 N GARDEN LN
Practice Address - Street 2:
Practice Address - City:NORTH GARDEN
Practice Address - State:VA
Practice Address - Zip Code:22959-1636
Practice Address - Country:US
Practice Address - Phone:434-531-1008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-09
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAIR000055343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA=========Medicaid