Provider Demographics
NPI:1104361138
Name:PORT ST. LUCIE OPERATIONS, LLC
Entity Type:Organization
Organization Name:PORT ST. LUCIE OPERATIONS, LLC
Other - Org Name:LIFE CARE CENTER OF PORT ST. LUCIE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:CROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-473-5867
Mailing Address - Street 1:3001 KEITH ST NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-3713
Mailing Address - Country:US
Mailing Address - Phone:423-473-5751
Mailing Address - Fax:423-339-8342
Practice Address - Street 1:3720 SE JENNINGS RD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7701
Practice Address - Country:US
Practice Address - Phone:772-398-8080
Practice Address - Fax:772-398-9365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
106012Medicare Oscar/Certification