MEDICARE: PINE ENTERPRISES, 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	305S00000X	Point of Service

General Provider Information

NPI Number	:	1174692685
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE ENTERPRISES, LLC

Provider Business Mailing Address
First Line	:	407 N BELCHER RD
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33765-2607
Country	:	US
Telephone Number	:	727-450-0700
Fax Number	:	888-271-2833

Provider Business Practice Location Address
First Line	:	407 N BELCHER RD
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33765-2607
Country	:	US
Telephone Number	:	727-450-0700
Fax Number	:	888-271-2833

Authorized Official
Title or Position	:	PRESIDENT
Name	:	STEVEN GRUNEBACH
Credential	:
Telephone Number	:	727-450-0700

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	08/22/2020

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