MEDICARE: PINEWOOD HARBOR, 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	311ZA0620X	Adult Care Home Facility

General Provider Information

NPI Number	:	1467732586
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINEWOOD HARBOR, LLC

Provider Business Mailing Address
First Line	:	325 SOUND RD
Second Line	:
City	:	HOLLY RIDGE
State	:	NC
Zip	:	28445-7813
Country	:	US
Telephone Number	:	910-329-9942
Fax Number	:	910-329-9943

Provider Business Practice Location Address
First Line	:	325 SOUND RD
Second Line	:
City	:	HOLLY RIDGE
State	:	NC
Zip	:	28445-7813
Country	:	US
Telephone Number	:	910-329-9942
Fax Number	:	910-329-9943

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	MS. BELINDA GRADY DELUCA
Credential	:
Telephone Number	:	910-249-3073

Provider Enumeration Date	:	08/20/2011
Last Update Date	:	08/20/2011

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