Provider Demographics
NPI:1184222002
Name:WICKSHIRE PORT ST. LUCIE
Entity Type:Organization
Organization Name:WICKSHIRE PORT ST. LUCIE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:O'KEEFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-942-0240
Mailing Address - Street 1:750 OLD HICKORY BLVD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4528
Mailing Address - Country:US
Mailing Address - Phone:615-942-0240
Mailing Address - Fax:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)