Provider Demographics
NPI:1447697347
Name:STAR ANGELS ADULT FAMILY CARE HOME
Entity type:Organization
Organization Name:STAR ANGELS ADULT FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:WEIR
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:772-233-2331
Mailing Address - Street 1:415 SW SADWICK AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953
Mailing Address - Country:US
Mailing Address - Phone:772-233-2331
Mailing Address - Fax:
Practice Address - Street 1:415 - SW SADWICK AVE.
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953
Practice Address - Country:US
Practice Address - Phone:772-233-2331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-31
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906565310400000X, 311Z00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility