MEDICARE: MCP STUART LODGE OPCO 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1598544413
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCP STUART LODGE OPCO LLC

Provider Business Mailing Address
First Line	:	12377 MERIT DR STE 500
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75251-2343
Country	:	US
Telephone Number	:	214-443-8300
Fax Number	:

Provider Business Practice Location Address
First Line	:	1301 SE PALM BEACH RD
Second Line	:
City	:	STUART
State	:	FL
Zip	:	34994-4012
Country	:	US
Telephone Number	:	772-837-5889
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	BRIAN BOLLICH
Credential	:
Telephone Number	:	214-443-8329

Provider Enumeration Date	:	09/28/2023
Last Update Date	:	09/28/2023

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