Provider Demographics
NPI:1427562073
Name:PINECREST PT-SOUTH L.L.C.
Entity Type:Organization
Organization Name:PINECREST PT-SOUTH L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:YACOUB
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:305-722-0568
Mailing Address - Street 1:13101 S DIXIE HWY STE 330
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-6530
Mailing Address - Country:US
Mailing Address - Phone:305-722-0568
Mailing Address - Fax:305-670-0899
Practice Address - Street 1:13101 S DIXIE HWY STE 330
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-6530
Practice Address - Country:US
Practice Address - Phone:305-722-0568
Practice Address - Fax:305-670-0899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-18
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT18067261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0000000OtherAPPLYING FOR MCR