Provider Demographics
NPI:1811335631
Name:PINE CREST MANOR K&V INC
Entity type:Organization
Organization Name:PINE CREST MANOR K&V INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST. ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VEERASAMY
Authorized Official - Middle Name:
Authorized Official - Last Name:VEERAMAH
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:904-272-2609
Mailing Address - Street 1:2835 COUNTY ROAD 220
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-4205
Mailing Address - Country:US
Mailing Address - Phone:904-272-2609
Mailing Address - Fax:904-731-0531
Practice Address - Street 1:2835 COUNTY ROAD 220
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-4205
Practice Address - Country:US
Practice Address - Phone:904-272-2609
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL7613310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1412272Medicaid