Healthcare Provider Details

I. General information

NPI: 1306810403
Provider Name (Legal Business Name): PINEHOUSE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

297 SW COUNTY ROAD 300
MAYO FL
32066-4402
US

IV. Provider business mailing address

297 SW COUNTY ROAD 300
MAYO FL
32066-4402
US

V. Phone/Fax

Practice location:
  • Phone: 386-294-5050
  • Fax: 386-294-5057
Mailing address:
  • Phone: 386-294-5050
  • Fax: 386-294-5057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL9863
License Number StateFL

VIII. Authorized Official

Name: MR. WAYMON W. THOMAS
Title or Position: PRESIDENT
Credential:
Phone: 386-294-5050