Provider Demographics
NPI:1760958847
Name:VITALITY STAR RESORT ALF LLC
Entity Type:Organization
Organization Name:VITALITY STAR RESORT ALF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:DORVAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-207-7947
Mailing Address - Street 1:11380 SW HILLCREST CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2704
Mailing Address - Country:US
Mailing Address - Phone:772-539-0405
Mailing Address - Fax:
Practice Address - Street 1:591 SW BRADSHAW CIR
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-5539
Practice Address - Country:US
Practice Address - Phone:772-207-7947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023404800Medicaid