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General NPI Number Information
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NPI Number | 1760624365
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Entity Type | Organization
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Legal Business Name | EGRET POND, LLC
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Dates
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Enumeration Date | 03/27/2009
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Last Update Date | 03/27/2009
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Provider Practice Location Address
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Address Line | 1760 SE SALERNO RD
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City | STUART
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State | FL
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Zip | 34997-6442
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Country | US
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Telephone | 772-288-1288
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Fax | 772-219-8458
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Provider Business Mailing Address
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Address Line | 1760 SE SALERNO RD
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City | STUART
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State | FL
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Zip | 34997-6442
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Country | US
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Telephone | 772-288-1288
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Fax | 772-219-8458
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Authorized Official
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Title or Position | OWNER
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Name | MR. ROBERT R. DELUCA
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Credential |
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Telephone | 772-288-1288
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | CE9977335
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License Number State | FL
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