MEDICARE: BRIGHTSTAR ASSISTED LIVING 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	385HR2065X	Child Physical Disabilities Respite Care
2	310400000X	Assisted Living Facility

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235851767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIGHTSTAR ASSISTED LIVING LLC

Provider Business Mailing Address
First Line	:	1613 SW MERIDIAN AVE
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-4300
Country	:	US
Telephone Number	:	954-864-9098
Fax Number	:	772-807-1866

Provider Business Practice Location Address
First Line	:	1613 SW MERIDIAN AVE
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-4300
Country	:	US
Telephone Number	:	954-864-9098
Fax Number	:	772-807-1866

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	GERMINE LORMERA
Credential	:
Telephone Number	:	954-864-9098

Provider Enumeration Date	:	09/12/2022
Last Update Date	:	09/27/2022

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Directions to “BRIGHTSTAR ASSISTED LIVING LLC ” Practice Location

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