MEDICARE: CONCIERGE HOME CARE OF PORT ST LUCIE LLC

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	251E00000X	Home Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10D2219901	OTHER	FL	CLIA WAIVER ID
2	299995197	OTHER	FL	AHCA STATE LICENSE

General Provider Information

NPI Number	:	1184222549
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONCIERGE HOME CARE OF PORT ST LUCIE LLC

Provider Business Mailing Address
First Line	:	4655 SALISBURY RD STE 110
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-0957
Country	:	US
Telephone Number	:	904-733-1003
Fax Number	:	904-448-8855

Provider Business Practice Location Address
First Line	:	1840 SE PORT ST LUCIE BLVD STE 1840
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-5545
Country	:	US
Telephone Number	:	772-777-2749
Fax Number	:	772-264-2900

Authorized Official
Title or Position	:	SECRETARY & CAO
Name	:	MR. ROBERT GREGORY YOUNG
Credential	:
Telephone Number	:	904-733-1003

Provider Enumeration Date	:	10/16/2020
Last Update Date	:	12/27/2023

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