Provider Demographics
NPI:1760852552
Name:ROSEWELL HOME AND RESIDENTIAL CARE, LLC
Entity Type:Organization
Organization Name:ROSEWELL HOME AND RESIDENTIAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:ICYLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-777-4463
Mailing Address - Street 1:3366 SW VENDOME ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-3407
Mailing Address - Country:US
Mailing Address - Phone:772-777-4463
Mailing Address - Fax:772-673-6203
Practice Address - Street 1:3366 SW VENDOME ST
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-3407
Practice Address - Country:US
Practice Address - Phone:772-777-4463
Practice Address - Fax:772-673-6203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12708310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility