Provider Demographics
NPI:1093748162
Name:OGLETHORPE OF PORT ST LUCIE LLC
Entity type:Organization
Organization Name:OGLETHORPE OF PORT ST LUCIE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CORPORATE DIRECTOR REVENUE CYCLE
Authorized Official - Prefix:MS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-895-0084
Mailing Address - Street 1:2550 SE WALTON RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7168
Mailing Address - Country:US
Mailing Address - Phone:772-335-0400
Mailing Address - Fax:772-337-3124
Practice Address - Street 1:2550 SE WALTON RD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7168
Practice Address - Country:US
Practice Address - Phone:772-335-0400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104070Medicare ID - Type UnspecifiedMEDICARE NUMBER