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General NPI Number Information
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NPI Number | 1760852552
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Entity Type | Organization
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Legal Business Name | ROSEWELL HOME AND RESIDENTIAL CARE, LLC
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Dates
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Enumeration Date | 10/06/2015
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Last Update Date | 10/06/2015
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Provider Practice Location Address
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Address Line | 3366 SW VENDOME ST
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34953-3407
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Country | US
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Telephone | 772-777-4463
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Fax | 772-673-6203
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Provider Business Mailing Address
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Address Line | 3366 SW VENDOME ST
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34953-3407
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Country | US
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Telephone | 772-777-4463
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Fax | 772-673-6203
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MISS ICYLIN DOUGLAS
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Credential |
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Telephone | 772-777-4463
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AL12708
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License Number State | FL
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