Healthcare Provider Details

I. General information

NPI: 1184142069
Provider Name (Legal Business Name): ST CLOUD OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 08/31/2017
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

480 FENTRESS BLVD STE H
DAYTONA BEACH FL
32114-1237
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 Number
License Number State

VIII. Authorized Official

Name: CAMERON MARSH
Title or Position: CORPORATE FINANCE
Credential:
Phone: 386-255-1054