Provider Demographics
NPI:1407023054
Name:PARADISE PORT ST LUCIE, LLC
Entity Type:Organization
Organization Name:PARADISE PORT ST LUCIE, LLC
Other - Org Name:PARADISE CARE COTTAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-398-8899
Mailing Address - Street 1:2277 SE LENNARD RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-6889
Mailing Address - Country:US
Mailing Address - Phone:772-398-8899
Mailing Address - Fax:772-398-3322
Practice Address - Street 1:2277 SE LENNARD RD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-6889
Practice Address - Country:US
Practice Address - Phone:772-398-8899
Practice Address - Fax:772-398-3322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL8585310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL679064000Medicaid