Provider Demographics
NPI:1760736524
Name:PEREGON, LLC
Entity Type:Organization
Organization Name:PEREGON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LANIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-298-1910
Mailing Address - Street 1:8064 SW 133RD CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33183-4130
Mailing Address - Country:US
Mailing Address - Phone:305-298-1910
Mailing Address - Fax:
Practice Address - Street 1:8064 SW 133RD CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-4130
Practice Address - Country:US
Practice Address - Phone:305-298-1910
Practice Address - Fax:786-358-6739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7492144032Medicaid