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General NPI Number Information
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NPI Number | 1770595738
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Entity Type | Organization
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Legal Business Name | ABBIEJEAN RUSSELL CARE CENTER, LLC
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Dates
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Enumeration Date | 08/11/2006
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Last Update Date | 07/31/2012
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Provider Practice Location Address
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Address Line | 700 S 29TH ST
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City | FORT PIERCE
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State | FL
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Zip | 34947-3626
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Country | US
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Telephone | 772-465-7560
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Fax | 772-465-5619
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Provider Business Mailing Address
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Address Line | 700 S 29TH ST
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City | FORT PIERCE
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State | FL
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Zip | 34947-3626
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Country | US
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Telephone | 772-465-7560
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Fax | 772-465-5619
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Authorized Official
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Title or Position | OWNER
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Name | MARIA ELVA GONZALEZ
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Credential |
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Telephone | 786-385-4364
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | SNF10020961
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License Number State | FL
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