MEDICARE: PINE MEADOWS HEALTH CARE, 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	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	100638	KY
2	332B00000X	Durable Medical Equipment & Medical Supplies	100638	KY
3	335E00000X	Prosthetic/Orthotic Supplier	100638	KY
4	332BN1400X	Nursing Facility Supplies (DME)
5	314000000X	Skilled Nursing Facility	100638	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000054920	OTHER	KY	ANTHEM BC/BS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952405573
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE MEADOWS HEALTH CARE, LLC

Provider Business Mailing Address
First Line	:	1608 HILL RISE DR
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40504-2503
Country	:	US
Telephone Number	:	859-254-2402
Fax Number	:

Provider Business Practice Location Address
First Line	:	1608 HILL RISE DR
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40504-2503
Country	:	US
Telephone Number	:	859-254-2402
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MARK BOWMAN
Credential	:
Telephone Number	:	859-272-6682

Provider Enumeration Date	:	09/12/2006
Last Update Date	:	10/02/2007

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Directions to “PINE MEADOWS HEALTH CARE, LLC ” Practice Location

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