Healthcare Provider Details

I. General information

NPI: 1174950158
Provider Name (Legal Business Name): TERRACE OF ST CLOUD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2013
Last Update Date: 11/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3855 OLD CANOE CREEK RD
SAINT CLOUD FL
34769-6628
US

IV. Provider business mailing address

3855 OLD CANOE CREEK RD
SAINT CLOUD FL
34769-6628
US

V. Phone/Fax

Practice location:
  • Phone: 407-957-2280
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1505096
License Number StateFL

VIII. Authorized Official

Name: CHARLES SHERER
Title or Position: ADMINISTRATOR
Credential:
Phone: 407-957-2280