MEDICARE: SOVEREIGN HEALTHCARE OF PORT ORANGE, 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	314000000X	Skilled Nursing Facility	SNF130471000	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	V573P-6386	OTHER	VA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710974423
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOVEREIGN HEALTHCARE OF PORT ORANGE, LLC

Provider Business Mailing Address
First Line	:	5887 GLENRIDGE DR
Second Line	:	SUITE 150
City	:	ATLANTA
State	:	GA
Zip	:	30328-5574
Country	:	US
Telephone Number	:	404-574-2100
Fax Number	:	404-574-2105

Provider Business Practice Location Address
First Line	:	5600 VICTORIA GARDENS BLVD
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-7914
Country	:	US
Telephone Number	:	386-760-7773
Fax Number	:	386-760-8949

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. R. MARK CRONQUIST
Credential	:
Telephone Number	:	404-574-2100

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	09/24/2014

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