Organization
SOVEREIGN HEALTHCARE OF PORT ORANGE, LLC
Active
Other names
Port Orange Nursing & Rehab Center
Organization subpart
No
Provider details
NPI number
Authorized official
MR. R. MARK CRONQUIST (MANAGER)
(404) 574-2100
Entity
Organization
Contact information
Practice address
5600 VICTORIA GARDENS BLVD, PORT ORANGE, FL 32127-7914
(386) 760-7773
(386) 760-8949
Mailing address
5887 GLENRIDGE DR, SUITE 150, ATLANTA, GA 30328-5574
(404) 574-2100
(404) 574-2105
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
SNF130471000
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
026350800
—
FL
01
—
V573P-6386
VA
—
Enumeration date
09/29/2005
Last updated
09/24/2014
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