Provider Demographics
NPI:1548244502
Name:PORT ST. LUCIE MGT LLC
Entity Type:Organization
Organization Name:PORT ST. LUCIE MGT LLC
Other - Org Name:EMERALD HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAVERN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:HERZOG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-668-9498
Mailing Address - Street 1:1655 SE WALTON RD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7657
Mailing Address - Country:US
Mailing Address - Phone:772-337-1333
Mailing Address - Fax:772-337-9856
Practice Address - Street 1:1655 SE WALTON RD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7657
Practice Address - Country:US
Practice Address - Phone:772-337-1333
Practice Address - Fax:772-337-9856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-02
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF14940961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL026163700Medicaid
FL026163700Medicaid
FL105579Medicare ID - Type Unspecified