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NPI Code Detail

MEDICARE: ABBIEJEAN RUSSELL CARE CENTER, LLC

MEDICARE: ABBIEJEAN RUSSELL CARE CENTER, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1314000000XSkilled Nursing FacilitySNF10020961FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2M4KOTHERFLBLUE CROSS BLUE SHIELD

General Provider Information

NPI Number : 1770595738
Entity Type Code : Organization
Provider Name (Legal Business Name) : ABBIEJEAN RUSSELL CARE CENTER, LLC
Provider Business Mailing Address
First Line : 700 S 29TH ST
Second Line :
City : FORT PIERCE
State : FL
Zip : 34947-3626
Country : US
Telephone Number : 772-465-7560
Fax Number : 772-465-5619
Provider Business Practice Location Address
First Line : 700 S 29TH ST
Second Line :
City : FORT PIERCE
State : FL
Zip : 34947-3626
Country : US
Telephone Number : 772-465-7560
Fax Number : 772-465-5619
Authorized Official
Title or Position : OWNER
Name : MARIA ELVA GONZALEZ
Credential :
Telephone Number : 786-385-4364
Provider Enumeration Date : 08/11/2006
Last Update Date : 07/31/2012

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