Healthcare Provider Details

I. General information

NPI: 1215690557
Provider Name (Legal Business Name): G2M4 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2021
Last Update Date: 03/06/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

549 NW LAKE WHITNEY PL STE 106
PORT ST LUCIE FL
34986-1606
US

IV. Provider business mailing address

549 NW LAKE WHITNEY PL STE 106
PORT ST LUCIE FL
34986-1606
US

V. Phone/Fax

Practice location:
  • Phone: 772-924-3210
  • Fax: 772-924-3210
Mailing address:
  • Phone: 772-924-3210
  • Fax: 772-924-3210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK ANTHONY C SANTIAGO
Title or Position: OWNER
Credential:
Phone: 760-593-8262