Provider Demographics
NPI:1235495086
Name:THE CORNERSTONES OF PORT ST. LUCIE, INC.
Entity type:Organization
Organization Name:THE CORNERSTONES OF PORT ST. LUCIE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:RINA
Authorized Official - Middle Name:
Authorized Official - Last Name:AIKENS-ABSALOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-370-8107
Mailing Address - Street 1:1102 SW IVANHOE ST
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-2542
Mailing Address - Country:US
Mailing Address - Phone:772-879-4950
Mailing Address - Fax:
Practice Address - Street 1:1910 SE RAINIER RD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7610
Practice Address - Country:US
Practice Address - Phone:772-337-4321
Practice Address - Fax:772-777-1159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12131310400000X, 3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113493600Medicaid
FLAL 12131OtherAHCA
FL673340998Medicaid