Provider Demographics
NPI:1972793057
Name:LP PORT ST JOE LLC
Entity type:Organization
Organization Name:LP PORT ST JOE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-568-7800
Mailing Address - Street 1:12201 BLUEGRASS PARKWAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2361
Mailing Address - Country:US
Mailing Address - Phone:502-568-7800
Mailing Address - Fax:502-568-7150
Practice Address - Street 1:220 9TH ST
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456-1924
Practice Address - Country:US
Practice Address - Phone:850-229-8244
Practice Address - Fax:850-229-1042
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LP CR HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-26
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1038096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105435Medicare Oscar/Certification
6061690001Medicare NSC