Healthcare Provider Details

I. General information

NPI: 1669988424
Provider Name (Legal Business Name): RK4, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 12/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19091 N DALE MABRY HWY
LUTZ FL
33548-4982
US

IV. Provider business mailing address

20001 GULF BVLD. SUITE 11
INDIAN SHORES FL
33774
US

V. Phone/Fax

Practice location:
  • Phone: 813-751-0557
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: KEVIN RYAN ROCKEFELLER
Title or Position: CFO
Credential:
Phone: 727-581-4648