1508349838 NPI number — MRS. EVITA KING STANDARD CARE ALF

Table of content: MRS. EVITA KING STANDARD CARE ALF (NPI 1508349838)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508349838 NPI number — MRS. EVITA KING STANDARD CARE ALF

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KING
Provider First Name:
EVITA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
STANDARD CARE ALF
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARTIN
Provider Other First Name:
RITA
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CAMELOT COURT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1508349838
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2233 MCKINLEY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33020-3054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-922-0808
Provider Business Mailing Address Fax Number:
954-922-0882

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2233 MCKINLEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33020-3054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-922-0808
Provider Business Practice Location Address Fax Number:
954-922-0882
Provider Enumeration Date:
09/12/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 385H00000X , with the licence number:  7096 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 310400000X , with the licence number: 7096 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100938600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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