MEDICARE: THE CORNERSTONES OF PORT ST. LUCIE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3104A0625X	Assisted Living Facility (Mental Illness)	11602	FL
2	310400000X	Assisted Living Facility	11602	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	11967589	OTHER	FL	AHCA NUMBER (FILE NUMBER)
3	11602	OTHER	FL	LICENSE NUMBER

General Provider Information

NPI Number	:	1114355278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE CORNERSTONES OF PORT ST. LUCIE, INC.

Provider Business Mailing Address
First Line	:	1102 SW IVANHOE ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34983-2542
Country	:	US
Telephone Number	:	772-879-4950
Fax Number	:	772-807-7544

Provider Business Practice Location Address
First Line	:	1102 SW IVANHOE ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34983-2542
Country	:	US
Telephone Number	:	772-879-4950
Fax Number	:	772-807-7544

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MS. DAWNMARIE LESALDO
Credential	:
Telephone Number	:	772-879-4950

Provider Enumeration Date	:	10/28/2013
Last Update Date	:	11/01/2022

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