MEDICARE: PANSY'S PLACE

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1265196661
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PANSY'S PLACE

Provider Business Mailing Address
First Line	:	1905 W BLUE HERON BLVD
Second Line	:
City	:	RIVIERA BEACH
State	:	FL
Zip	:	33404-5149
Country	:	US
Telephone Number	:	561-287-0305
Fax Number	:	567-247-7627

Provider Business Practice Location Address
First Line	:	2058 PINEHURST DR
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33407-3546
Country	:	US
Telephone Number	:	561-287-0305
Fax Number	:	561-247-7627

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	MS. SHEMIA TIERRE PRINCE
Credential	:
Telephone Number	:	561-287-0308

Provider Enumeration Date	:	10/22/2021
Last Update Date	:	10/22/2021

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Directions to “PANSY'S PLACE ” Practice Location

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