Healthcare Provider Details

I. General information

NPI: 1447697347
Provider Name (Legal Business Name): STAR ANGELS ADULT FAMILY CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2013
Last Update Date: 05/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 - SW SADWICK AVE.
PORT SAINT LUCIE FL
34953
US

IV. Provider business mailing address

415 SW SADWICK AVE
PORT SAINT LUCIE FL
34953
US

V. Phone/Fax

Practice location:
  • Phone: 772-233-2331
  • Fax:
Mailing address:
  • Phone: 772-233-2331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number6906565
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number6906565
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number6906565
License Number StateFL

VIII. Authorized Official

Name: RITA FRANKLIN WEIR
Title or Position: ADMINISTRATOR
Credential: CNA
Phone: 772-233-2331