MEDICARE: PINE MEADOWSIDENCE OPCO, 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	314000000X	Skilled Nursing Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134545668
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE MEADOWSIDENCE OPCO, LLC

Provider Business Mailing Address
First Line	:	262 N UNIVERSITY AVE
Second Line	:
City	:	FARMINGTON
State	:	UT
Zip	:	84025-2975
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1608 HILL RISE DR
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40504-2503
Country	:	US
Telephone Number	:	859-254-2402
Fax Number	:

Authorized Official
Title or Position	:	SECRETARY
Name	:	JOHN MITCHELL
Credential	:
Telephone Number	:	385-988-3319

Provider Enumeration Date	:	03/07/2014
Last Update Date	:	08/21/2024

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