MEDICARE: ROSEWOOD GARDEN OF PORT ST.LUCIE

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
1	310400000X	Assisted Living Facility	AL9627	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801238159
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROSEWOOD GARDEN OF PORT ST.LUCIE

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

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

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. AGNES JOAN LESLIE
Credential	:
Telephone Number	:	772-224-9746

Provider Enumeration Date	:	07/26/2013
Last Update Date	:	07/26/2013

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