Healthcare Provider Details

I. General information

NPI: 1932853736
Provider Name (Legal Business Name): K2 ESCAPE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2022
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 W BLOOMINGDALE AVE
BRANDON FL
33511-7754
US

IV. Provider business mailing address

1005 W BLOOMINGDALE AVE
BRANDON FL
33511-7754
US

V. Phone/Fax

Practice location:
  • Phone: 813-440-7815
  • Fax:
Mailing address:
  • Phone: 813-440-7815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: ESSIE WILSON
Title or Position: CEO
Credential:
Phone: 813-440-7815