Healthcare Provider Details

I. General information

NPI: 1912562471
Provider Name (Legal Business Name): KJCARES SUPORTIVE LIVING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 05/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 FIRST STREET APT 5
ST. AUGUSTINE FL
32084
US

IV. Provider business mailing address

20 FIRST STREET APT 5
ST. AUGUSTINE FL
32084
US

V. Phone/Fax

Practice location:
  • Phone: 904-293-6757
  • Fax:
Mailing address:
  • Phone: 904-293-6757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: KEVIN ROBERTS
Title or Position: OWNER/DIRECTOR
Credential:
Phone: 904-293-6757