Healthcare Provider Details

I. General information

NPI: 1144663261
Provider Name (Legal Business Name): KIMBERLY BLACK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2013
Last Update Date: 12/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3794 VICTORIA RD
WEST PALM BCH FL
33411-6440
US

IV. Provider business mailing address

3794 VICTORIA RD
WEST PALM BCH FL
33411-6440
US

V. Phone/Fax

Practice location:
  • Phone: 561-629-5067
  • Fax:
Mailing address:
  • Phone: 561-629-5067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number6906527
License Number StateFL

VIII. Authorized Official

Name: KIMBERLY BLACK
Title or Position: ADMINISTRATOR
Credential:
Phone: 561-629-5067