Provider Demographics
NPI:1265862080
Name:RETREAT ON BYWOOD
Entity type:Organization
Organization Name:RETREAT ON BYWOOD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROOVENS
Authorized Official - Middle Name:
Authorized Official - Last Name:PIERRE LOUIS
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:404-707-0784
Mailing Address - Street 1:990 SE BYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-4065
Mailing Address - Country:US
Mailing Address - Phone:773-333-2203
Mailing Address - Fax:772-333-2203
Practice Address - Street 1:990 SE BYWOOD AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-4065
Practice Address - Country:US
Practice Address - Phone:773-333-2203
Practice Address - Fax:772-333-2203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12435310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility