Provider Demographics
NPI:1174780563
Name:MERRILL GARDENS PORT ST. LUCIE
Entity type:Organization
Organization Name:MERRILL GARDENS PORT ST. LUCIE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF WELLNESS
Authorized Official - Prefix:MS
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:BLAIR
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:772-337-0084
Mailing Address - Street 1:9825 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5626
Mailing Address - Country:US
Mailing Address - Phone:772-337-0084
Mailing Address - Fax:772-335-2662
Practice Address - Street 1:9825 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5626
Practice Address - Country:US
Practice Address - Phone:772-337-0084
Practice Address - Fax:772-335-2662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9628310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility