Healthcare Provider Details

I. General information

NPI: 1275814121
Provider Name (Legal Business Name): KYDD AT HEART ADULT FAMILY HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2011
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4810 18TH AVE SE STE 2
LACEY WA
98503-2652
US

IV. Provider business mailing address

4810 18TH AVE SE STE 2
LACEY WA
98503-2652
US

V. Phone/Fax

Practice location:
  • Phone: 360-790-2863
  • Fax:
Mailing address:
  • Phone: 360-790-2863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number752014
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number752014
License Number StateWA

VIII. Authorized Official

Name: WENDY ANN KYDD
Title or Position: PROVIDER
Credential: CNA
Phone: 360-790-2863