Healthcare Provider Details

I. General information

NPI: 1114922572
Provider Name (Legal Business Name): M-K OF NORTH PORT L L C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2005
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6940 OUTREACH WAY
NORTH PORT FL
34287-3405
US

IV. Provider business mailing address

6940 OUTREACH WAY
NORTH PORT FL
34287-3405
US

V. Phone/Fax

Practice location:
  • Phone: 941-426-8411
  • Fax: 941-423-1572
Mailing address:
  • Phone: 941-426-8411
  • Fax: 941-423-1572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1455095
License Number StateFL

VIII. Authorized Official

Name: MRS. LORI KING
Title or Position: ADMINISTRATOR
Credential:
Phone: 941-426-8411