MEDICARE: PETER THE GREAT II 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	3104A0625X	Assisted Living Facility (Mental Illness)

General Provider Information

NPI Number	:	1366312670
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETER THE GREAT II LLC

Provider Business Mailing Address
First Line	:	1722 MADISON ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33020-5537
Country	:	US
Telephone Number	:	954-923-1726
Fax Number	:	954-923-8535

Provider Business Practice Location Address
First Line	:	1722 MADISON ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33020-5537
Country	:	US
Telephone Number	:	954-923-1726
Fax Number	:	954-923-8535

Authorized Official
Title or Position	:	OWNER
Name	:	LEONID AVERBUKH
Credential	:
Telephone Number	:	917-913-9966

Provider Enumeration Date	:	11/11/2025
Last Update Date	:	11/11/2025

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