Provider Demographics
NPI:1720295140
Name:QUALITY CARE ASSISTED LIVING OF THE TREASURE COAST INC.
Entity Type:Organization
Organization Name:QUALITY CARE ASSISTED LIVING OF THE TREASURE COAST INC.
Other - Org Name:QUALITY CARE 2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DERIENZO
Authorized Official - Suffix:
Authorized Official - Credentials:CAREGIVER
Authorized Official - Phone:772-879-2501
Mailing Address - Street 1:432 SW PRADO AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-8750
Mailing Address - Country:US
Mailing Address - Phone:772-879-2501
Mailing Address - Fax:772-879-0136
Practice Address - Street 1:432 SW PRADO AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-8750
Practice Address - Country:US
Practice Address - Phone:772-879-2501
Practice Address - Fax:772-879-0136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9258310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL678899898Medicaid
FL142093300Medicaid
FL678899896Medicaid