Provider Demographics
NPI:1801238159
Name:ROSEWOOD GARDEN OF PORT ST.LUCIE
Entity type:Organization
Organization Name:ROSEWOOD GARDEN OF PORT ST.LUCIE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AGNES
Authorized Official - Middle Name:JOAN
Authorized Official - Last Name:LESLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-224-9746
Mailing Address - Street 1:643 NE LAGOON LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-1226
Mailing Address - Country:US
Mailing Address - Phone:772-344-5974
Mailing Address - Fax:772-879-7587
Practice Address - Street 1:643 NE LAGOON LN
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-1226
Practice Address - Country:US
Practice Address - Phone:772-344-5974
Practice Address - Fax:772-879-7587
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9627310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL685393500Medicaid