Healthcare Provider Details

I. General information

NPI: 1114355278
Provider Name (Legal Business Name): THE CORNERSTONES OF PORT ST. LUCIE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2013
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 SW IVANHOE ST
PORT SAINT LUCIE FL
34983-2542
US

IV. Provider business mailing address

1102 SW IVANHOE ST
PORT SAINT LUCIE FL
34983-2542
US

V. Phone/Fax

Practice location:
  • Phone: 772-879-4950
  • Fax: 772-807-7544
Mailing address:
  • Phone: 772-879-4950
  • Fax: 772-807-7544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number11602
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number11602
License Number StateFL

VIII. Authorized Official

Name: MS. DAWNMARIE LESALDO
Title or Position: DIRECTOR
Credential:
Phone: 772-879-4950