MEDICARE: PINECREST CONVALESCENT CENTER, 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	13413	FL
2	314000000X	Skilled Nursing Facility	14400961	FL

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	:	1871503417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINECREST CONVALESCENT CENTER, LLC

Provider Business Mailing Address
First Line	:	13650 NE 3RD CT
Second Line	:
City	:	NORTH MIAMI
State	:	FL
Zip	:	33161-3626
Country	:	US
Telephone Number	:	305-893-1170
Fax Number	:	305-899-2817

Provider Business Practice Location Address
First Line	:	13650 NE 3RD CT
Second Line	:
City	:	NORTH MIAMI
State	:	FL
Zip	:	33161-3626
Country	:	US
Telephone Number	:	305-893-1170
Fax Number	:	305-899-2817

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. DAVID GOLD
Credential	:	LCSW, MBA
Telephone Number	:	305-893-1170

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	01/27/2015

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