Healthcare Provider Details

I. General information

NPI: 1174992622
Provider Name (Legal Business Name): PINEWOOD ESTATES ASSISTED LIVING FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 09/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 PINEWOOD RD
MELBOURNE FL
32934-9053
US

IV. Provider business mailing address

PO BOX 640902
MIAMI FL
33164-0902
US

V. Phone/Fax

Practice location:
  • Phone: 786-376-4043
  • Fax:
Mailing address:
  • Phone: 786-376-4043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL12678
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberAL12678
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberAL12678
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberAL12678
License Number StateFL

VIII. Authorized Official

Name: MR. PETER D. FELLOWS
Title or Position: DIRECTOR
Credential:
Phone: 786-376-4043