Healthcare Provider Details

I. General information

NPI: 1023269354
Provider Name (Legal Business Name): BKK SERVICE OF CENTRAL FLORIDA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2008
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 S FLORIDA AVE SUITE 201
LAKELAND FL
33803-1183
US

IV. Provider business mailing address

902 S FLORIDA AVE SUITE 201
LAKELAND FL
33803-1183
US

V. Phone/Fax

Practice location:
  • Phone: 863-701-9100
  • Fax: 863-644-8077
Mailing address:
  • Phone: 863-701-9100
  • Fax: 863-644-8077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number299992766
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number228316
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number229362
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number230019
License Number StateFL

VIII. Authorized Official

Name: TRACY DEAN KELLEY
Title or Position: CEO
Credential:
Phone: 863-701-9100