Basic Information
| Provider Information | |||||||||
| NPI: | 1134143845 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 1240 PINEBROOK ROAD LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PINEBROOK CARE AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 SUN AVE NE | ||||||||
| Address2: | COMPLIANCE DEPARTMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054685604 | ||||||||
| FaxNumber: | 5054684681 | ||||||||
| Practice Location | |||||||||
| Address1: | 1240 PINEBROOK RD | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342856421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414886733 | ||||||||
| FaxNumber: | 9414847924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 10/01/2009 | ||||||||
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| AuthorizedOfficialLastName: | MATHIES | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5058213355 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUNBRIDGE HEALTHCARE CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | SNF 14390962 | FL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 025266200 | 05 | FL | MEDICAID |