Healthcare Provider Details

I. General information

NPI: 1043887631
Provider Name (Legal Business Name): PORT ST LUCIE NURSING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2021
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

3599 W LAKE MARY BLVD
LAKE MARY FL
32746-3417
US

V. Phone/Fax

Practice location:
  • Phone: 772-337-1333
  • Fax: 772-337-6485
Mailing address:
  • Phone: 352-874-6007
  • Fax: 352-404-4078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: VICTORIA SHARPLESS
Title or Position: DIRECTOR OF ACCOUNTING
Credential:
Phone: 352-874-6007