Healthcare Provider Details

I. General information

NPI: 1811673189
Provider Name (Legal Business Name): KUKU 4 COCO BEACH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 W OAK AVE
PANAMA CITY FL
32401-2735
US

IV. Provider business mailing address

5153 HOLLY FERN TRCE
TALLAHASSEE FL
32312-7583
US

V. Phone/Fax

Practice location:
  • Phone: 850-661-0362
  • Fax:
Mailing address:
  • Phone: 850-251-2718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. KURT BOWMAN
Title or Position: OWNER
Credential:
Phone: 850-661-0362