Provider Demographics
NPI:1871503417
Name:PINECREST CONVALESCENT CENTER, LLC
Entity Type:Organization
Organization Name:PINECREST CONVALESCENT CENTER, LLC
Other - Org Name:PINECREST REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, MBA
Authorized Official - Phone:305-893-1170
Mailing Address - Street 1:13650 NE 3RD CT
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-3626
Mailing Address - Country:US
Mailing Address - Phone:305-893-1170
Mailing Address - Fax:305-899-2817
Practice Address - Street 1:13650 NE 3RD CT
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-3626
Practice Address - Country:US
Practice Address - Phone:305-893-1170
Practice Address - Fax:305-899-2817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13413314000000X
FL14400961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022575400Medicaid
FL1871503487Medicare UPIN
105153Medicare Oscar/Certification
FL105153Medicare Oscar/Certification