Healthcare Provider Details

I. General information

NPI: 1356687222
Provider Name (Legal Business Name): THE KIDZ CLUB- ST PETE,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2012
Last Update Date: 12/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 HERR LN
LOUISVILLE KY
40222-4301
US

IV. Provider business mailing address

850 3RD AVE S
ST PETERSBURG FL
33701-4033
US

V. Phone/Fax

Practice location:
  • Phone: 502-210-5538
  • Fax: 502-327-5098
Mailing address:
  • Phone: 727-821-5439
  • Fax: 727-821-9459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number2929960060
License Number StateFL

VIII. Authorized Official

Name: DEBBIE A HUNT
Title or Position: VP OF OPERATIONS
Credential:
Phone: 502-458-5433