Healthcare Provider Details

I. General information

NPI: 1629582440
Provider Name (Legal Business Name): FOUR HEARTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2017
Last Update Date: 05/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 W 14TH ST
RIVIERA BEACH FL
33404
US

IV. Provider business mailing address

PO BOX 10452
RIVIERA BEACH FL
33419-0452
US

V. Phone/Fax

Practice location:
  • Phone: 561-876-1541
  • Fax:
Mailing address:
  • Phone: 561-876-1541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number234977
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. JEWEL ELOIS MCDONALD
Title or Position: CEO
Credential:
Phone: 561-876-1541