Provider Demographics
NPI:1184222549
Name:CONCIERGE HOME CARE OF PORT ST LUCIE LLC
Entity Type:Organization
Organization Name:CONCIERGE HOME CARE OF PORT ST LUCIE LLC
Other - Org Name:CONCIERGE HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY & CAO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-733-1003
Mailing Address - Street 1:4655 SALISBURY RD STE 110
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0957
Mailing Address - Country:US
Mailing Address - Phone:904-733-1003
Mailing Address - Fax:904-448-8855
Practice Address - Street 1:1840 SE PORT ST LUCIE BLVD STE 1840
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5545
Practice Address - Country:US
Practice Address - Phone:772-777-2749
Practice Address - Fax:772-264-2900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-16
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10D2219901OtherCLIA WAIVER ID
FL299995197OtherAHCA STATE LICENSE