Healthcare Provider Details

I. General information

NPI: 1417611369
Provider Name (Legal Business Name): ST AUGUSTINE FL OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 MARINE ST
SAINT AUGUSTINE FL
32084-5154
US

IV. Provider business mailing address

980 SYLVAN AVE
ENGLEWOOD CLIFFS NJ
07632-3301
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-3475
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: BATYA GORELICK
Title or Position: COO
Credential:
Phone: 904-829-3475