Healthcare Provider Details

I. General information

NPI: 1134143845
Provider Name (Legal Business Name): 1240 PINEBROOK ROAD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 10/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 PINEBROOK RD
VENICE FL
34285-6421
US

IV. Provider business mailing address

101 SUN AVE NE COMPLIANCE DEPARTMENT
ALBUQUERQUE NM
87109-4373
US

V. Phone/Fax

Practice location:
  • Phone: 941-488-6733
  • Fax: 941-484-7924
Mailing address:
  • Phone: 505-468-5604
  • Fax: 505-468-4681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF 14390962
License Number StateFL

VIII. Authorized Official

Name: WILLIAM A MATHIES
Title or Position: PRESIDENT DIRECTOR
Credential:
Phone: 505-821-3355