MEDICARE: TERRACINA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	AL10071	FL

General Provider Information

NPI Number	:	1184665077
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TERRACINA, LLC

Provider Business Mailing Address
First Line	:	1107 HAZELTINE BLVD
Second Line	:	SUITE 200
City	:	CHASKA
State	:	MN
Zip	:	55318-1009
Country	:	US
Telephone Number	:	952-361-8000
Fax Number	:	952-361-8058

Provider Business Practice Location Address
First Line	:	6825 DAVIS BLVD
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34104-5322
Country	:	US
Telephone Number	:	239-455-1459
Fax Number	:	239-455-7359

Authorized Official
Title or Position	:	PRESIDENT OF MANAGING MEMBER
Name	:	MR. JOHN B GOODMAN
Credential	:
Telephone Number	:	952-361-8000

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	08/22/2020

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