MEDICARE: GRAND BOULEVARD OPERATING INVESTMENTS 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	:	1386398501
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND BOULEVARD OPERATING INVESTMENTS LLC

Provider Business Mailing Address
First Line	:	2901 STIRLING RD STE 200
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-6529
Country	:	US
Telephone Number	:	954-300-3878
Fax Number	:

Provider Business Practice Location Address
First Line	:	138 SANDESTIN LN
Second Line	:
City	:	MIRAMAR BEACH
State	:	FL
Zip	:	32550-5815
Country	:	US
Telephone Number	:	954-300-3878
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MR. JACOB BENGIO
Credential	:
Telephone Number	:	954-300-3878

Provider Enumeration Date	:	02/07/2022
Last Update Date	:	02/07/2022

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