Organization
PINE GROVE INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JAMES D. MOEN (EXECUTIVE DIRECTOR)
(803) 438-3011
Entity
Organization
Contact information
Practice address
1500 CHESTNUT ROAD, ELGIN, SC 29045-0100
(803) 438-3011
(803) 438-8611
Mailing address
PO BOX 100, ELGIN, SC 29045-0100
(803) 438-3011
(803) 438-8611
Taxonomy
Speciality
Code
Description
License number
State
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
Primary
SR0008132001CCI
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
961MXH
—
SC
Enumeration date
01/03/2007
Last updated
08/22/2020
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