Provider Demographics
NPI:1649974387
Name:PORT ST. LUCIE FL OPCO LLC
Entity type:Organization
Organization Name:PORT ST. LUCIE FL OPCO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BATYA
Authorized Official - Middle Name:
Authorized Official - Last Name:GORELICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-928-7808
Mailing Address - Street 1:1655 SE WALTON RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7657
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1655 SE WALTON RD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7657
Practice Address - Country:US
Practice Address - Phone:772-337-1333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility