Healthcare Provider Details

I. General information

NPI: 1073550489
Provider Name (Legal Business Name): PINEWOOD HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 04/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2514 N 7TH ST
COEUR D ALENE ID
83814-3720
US

IV. Provider business mailing address

2514 N 7TH ST
COEUR D ALENE ID
83814-3720
US

V. Phone/Fax

Practice location:
  • Phone: 208-664-8128
  • Fax: 208-765-0505
Mailing address:
  • Phone: 208-664-8128
  • Fax: 208-765-0505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number33
License Number StateID

VIII. Authorized Official

Name: MASON A. HUNTER
Title or Position: MANAGER
Credential:
Phone: 208-664-8128