Provider Demographics
NPI:1922180249
Name:ST LUCIE GENERAL SURGERY LLC
Entity type:Organization
Organization Name:ST LUCIE GENERAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-335-7606
Mailing Address - Street 1:1700 SE HILLMOOR DR
Mailing Address - Street 2:SUITE 503
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7539
Mailing Address - Country:US
Mailing Address - Phone:772-335-7606
Mailing Address - Fax:
Practice Address - Street 1:1700 SE HILLMOOR DR
Practice Address - Street 2:SUITE 503
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7539
Practice Address - Country:US
Practice Address - Phone:772-335-7606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty