Provider Demographics
NPI:1861544579
Name:PINE HAVEN HOME HEALTH CARE SERVICES INC
Entity type:Organization
Organization Name:PINE HAVEN HOME HEALTH CARE SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:252-523-1963
Mailing Address - Street 1:1108 N HERRITAGE ST
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-3834
Mailing Address - Country:US
Mailing Address - Phone:252-523-1963
Mailing Address - Fax:252-523-1123
Practice Address - Street 1:1108 N HERRITAGE ST
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501-3834
Practice Address - Country:US
Practice Address - Phone:252-523-1963
Practice Address - Fax:252-523-1123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC1411251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408724Medicaid
NC6600438Medicaid
NC6600841Medicaid
NC6600889Medicaid