1801238159 NPI number — ROSEWOOD GARDEN OF PORT ST.LUCIE

Table of content: (NPI 1801238159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801238159 NPI number — ROSEWOOD GARDEN OF PORT ST.LUCIE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSEWOOD GARDEN OF PORT ST.LUCIE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801238159
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
643 NE LAGOON LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34983-1226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-344-5974
Provider Business Mailing Address Fax Number:
772-879-7587

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
643 NE LAGOON LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ST LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34983-1226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-344-5974
Provider Business Practice Location Address Fax Number:
772-879-7587
Provider Enumeration Date:
07/26/2013

Additional Information

Authorized Official

Authorized Official Last Name:
LESLIE
Authorized Official First Name:
AGNES
Authorized Official Middle Name:
JOAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
772-224-9746

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL9627 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 685393500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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