NPIMap

Organization Active NPI

Sovereign Healthcare of Port Orange, LLC

Doing business as Port Orange Nursing & Rehab Center

  • Skilled Nursing Facility
  • Port Orange, FL
National Provider Identifier
1710974423
Registry record updated Sep 24, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
SNF130471000 Issued in FL
Legal business name
SOVEREIGN HEALTHCARE OF PORT ORANGE, LLC
Doing business as
Port Orange Nursing & Rehab Center
Practice address
5600 Victoria Gardens Blvd
Port Orange, FL 32127-7914
Phone
(386) 760-7773
Fax
(386) 760-8949
NPI assigned
Sep 29, 2005
Last updated
Sep 24, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 24, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. R. Mark Cronquist
Title
Manager
Phone
(404) 574-2100

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X SNF130471000 FL Primary

Addresses

Primary practice location

5600 Victoria Gardens Blvd
Port Orange, FL 32127-7914

Mailing address

5887 Glenridge Dr
Suite 150
Atlanta, GA 30328-5574
Phone (404) 574-2100

Other identifiers 2

IdentifierTypeStateIssuer
V573P-6386OtherVA
026350800MedicaidFL

Other names 1

  • Port Orange Nursing & Rehab Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20030903000016 FL Part A Provider - Skilled Nursing Facility 5890606131 Practice locations: Port Orange, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1710974423. Details of each certification follow.

Skilled nursing facility certification: CCN 105776

Legal name
SOVEREIGN HEALTHCARE OF PORT ORANGE LLC
Doing business as
PORT ORANGE NURSING AND REHAB CENTER
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Oct 9, 1992
Last certification
Jun 20, 2024
Beds
120
Ownership / control type
Limited Liability Corporation
Multi-facility organization
Sovereign Healthcare Holdings, LLC
Organization structure
LLCProprietary
Enrollment address
5600 Victoria Gardens Blvd
Port Orange, FL 32127-7914
Nursing home name
PORT ORANGE NURSING AND REHAB CENTER
Affiliated entity
SOVEREIGN HEALTHCARE HOLDINGS

Care Compare: Nursing home

Medicare Care Compare
Listed as
Port Orange Nursing and Rehab CenterCCN 105776 · All quality measures
Overall star rating
3 of 5
Health inspections
2 of 5
Staffing
2 of 5
Quality measures
5 of 5
Type
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified
Oct 9, 1992
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
120109.6 residents per day on average
Chain
Sovereign Healthcare Holdings43 facilities in the chain
Abuse citation
Cited for abuse (Care Compare abuse icon)

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
10D0861326Port Orange Nursing and Rehab Center5600 Victoria Gardens Blvd, Port Orange, FL 32127Certificate of waiverAug 31, 2026

National Provider Directory

National Provider Directory

Networks

  • Freedom Health HMO NetworkPlans: Freedom Platinum Rewards Plan Rx (HMO) (H5427-102-000, H5427); Freedom VIP Care (HMO C-SNP) (H5427-070-000, H5427); Freedom VIP Rewards (HMO C-SNP) (H5427-108-000, H5427); Freedom VIP Rewards (HMO C-SNP) (H5427-099-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-107-000, H5427); Freedom Máximo (HMO-POS) (H5427-113-000, H5427); Freedom Savings Plan (HMO) (H5427-052-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-096-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-105-000, H5427); Freedom Medi-Medi Full (HMO D-SNP) (H5427-087-000, H5427)…
  • Optimum HealthCare HMO NetworkPlans: Optimum Diamond Rewards (HMO C-SNP) (H5594-028-000, H5594); Optimum Diamond (HMO C-SNP) (H5594-036-000, H5594); Optimum Diamond Rewards (HMO C-SNP) (H5594-034-000, H5594); Optimum Diamond Rewards COPD (HMO C-SNP) (H5594-029-000, H5594); Optimum Platinum Plan (HMO) (H5594-002-000, H5594); Optimum Gold Plus Plan (HMO) (H5594-032-000, H5594); Optimum Diamond Savings COPD (HMO C-SNP) (H5594-031-000, H5594); Optimum Diamond Savings (HMO C-SNP) (H5594-030-000, H5594); Optimum Diamond Rewards COPD (HMO C-SNP) (H5594-035-000, H5594)

Ownership & related parties

All disclosed owners & managing parties 15

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Susan Kaar Individual Managing Control - Governing BodyVP of Compliance and Quality MGN Oct 1, 2003
Adp of the SNF Oct 1, 2003
Sovereign Healthcare Disbursements LLC Organization, Casselberry, FL LLC Adp of the SNF May 19, 2009
Henry Gerrity Individual Managing Control - Governing BodyVP of Operations Apr 1, 2014
Adp of the SNF Apr 1, 2014
Southern Healthcare Management LLC Organization, Casselberry, FL For-profit Operational/Managerial Control May 19, 2009
Adp of the SNF Oct 8, 2025
FL Port Orange Holdings LLC Organization, Miami, FL LLC 5% Or Greater Security Interest May 19, 2009 100%
Adp of the SNF May 19, 2009
Michelle Kelly Individual Adp of the SNF Feb 1, 2018
Donald K Melton Individual Operational/Managerial Control Feb 15, 2009
Adp of the SNF Feb 15, 2009
Sovereign Healthcare Holdings LLC Organization, Atlanta, GA LLC, Holding company, For-profit, Chain home office, Owned by another organization or individual Direct Ownership Interest May 19, 2019
Laura Haraburda Individual Operational/Managerial Control Mar 30, 2026
Adp of the SNF Mar 30, 2026
Berkadia Commercial Mortgage LLC Organization, Horsham, PA Financial institution 5% Or Greater Security Interest Jun 30, 2014 100%
Royce M Cronquist Individual Operational/Managerial Control Feb 1, 2018
Adp of the SNF Feb 1, 2018
Husam E Eddin Individual Operational/Managerial Control Oct 11, 2022
Adp of the SNF Oct 11, 2022
Forvis Mazars LLP Organization, Springfield, MO Adp of the SNF Jan 1, 2025
Dawn Chery Individual Managing Control - Governing BodyCheif Nursing Officer Jun 8, 2017
Adp of the SNF Jun 8, 2017
Health Services Properties LLC Organization, Casselberry, FL LLC, Owned by another organization or individual 5% Or Greater Security Interest May 19, 2009 100%
Adp of the SNF May 19, 2009

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 41

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 41

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1127952000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1411516800000",
    "number": "1710974423",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5887 GLENRIDGE DR",
            "address_2": "SUITE 150",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303285574",
            "telephone_number": "404-574-2100",
            "fax_number": "404-574-2105"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5600 VICTORIA GARDENS BLVD",
            "city": "PORT ORANGE",
            "state": "FL",
            "postal_code": "321277914",
            "telephone_number": "386-760-7773",
            "fax_number": "386-760-8949"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOVEREIGN HEALTHCARE OF PORT ORANGE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-09-29",
        "last_updated": "2014-09-24",
        "status": "A",
        "authorized_official_last_name": "CRONQUIST",
        "authorized_official_first_name": "R.",
        "authorized_official_middle_name": "MARK",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "404-574-2100",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "FL",
            "license": "SNF130471000",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "VA",
            "identifier": "V573P-6386",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "026350800",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Port Orange Nursing & Rehab Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Port Orange, FL

Sources for this page

Verify at the official NPI Registry.