Basic Information
| Provider Information | |||||||||
| NPI: | 1174780563 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERRILL GARDENS PORT ST. LUCIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9825 S US HIGHWAY 1 | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349525626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723370084 | ||||||||
| FaxNumber: | 7723352662 | ||||||||
| Practice Location | |||||||||
| Address1: | 9825 S US HIGHWAY 1 | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349525626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723370084 | ||||||||
| FaxNumber: | 7723352662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2008 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | SHEPHERD | ||||||||
| AuthorizedOfficialFirstName: | ASHLEY | ||||||||
| AuthorizedOfficialMiddleName: | BLAIR | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF WELLNESS | ||||||||
| AuthorizedOfficialTelephone: | 7723370084 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LPN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AL9628 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.