Provider Demographics
NPI:1205643442
Name:PINE LODGE BUSINESS LLC
Entity type:Organization
Organization Name:PINE LODGE BUSINESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NISSA NASIR
Authorized Official - Middle Name:
Authorized Official - Last Name:HUSAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-606-0550
Mailing Address - Street 1:3639 COPPER STONE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-6257
Mailing Address - Country:US
Mailing Address - Phone:214-606-0550
Mailing Address - Fax:
Practice Address - Street 1:1667 W PLANO PKWY
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-8666
Practice Address - Country:US
Practice Address - Phone:214-606-0550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-11
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)