MEDICARE: PINEDA GROUP 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1205492568
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINEDA GROUP LLC

Provider Business Mailing Address
First Line	:	4325 N TORREY PINES DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-5510
Country	:	US
Telephone Number	:	702-658-5518
Fax Number	:	702-202-3680

Provider Business Practice Location Address
First Line	:	3421 CAMSORE POINT LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-6999
Country	:	US
Telephone Number	:	702-255-9171
Fax Number	:	702-202-3680

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	YANNIE TABLIZO
Credential	:
Telephone Number	:	702-302-6932

Provider Enumeration Date	:	05/13/2019
Last Update Date	:	05/13/2019

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