Healthcare Provider Details

I. General information

NPI: 1548244502
Provider Name (Legal Business Name): PORT ST. LUCIE MGT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 SE WALTON RD
PORT SAINT LUCIE FL
34952-7657
US

IV. Provider business mailing address

1655 SE WALTON RD
PORT SAINT LUCIE FL
34952-7657
US

V. Phone/Fax

Practice location:
  • Phone: 772-337-1333
  • Fax: 772-337-9856
Mailing address:
  • Phone: 772-337-1333
  • Fax: 772-337-9856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF14940961
License Number StateFL

VIII. Authorized Official

Name: MR. LAVERN PATRICK HERZOG
Title or Position: PRESIDENT
Credential:
Phone: 386-668-9498