Provider Demographics
NPI:1871316257
Name:PINE GROVE ASSOCIATION
Entity type:Organization
Organization Name:PINE GROVE ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-955-1132
Mailing Address - Street 1:1134 BARNES RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-0036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1134 BARNES RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046
Practice Address - Country:US
Practice Address - Phone:601-761-9424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty