=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013934660
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COREY KARE HOME & COMMUNITY SUPPORT SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2006
-----------------------------------------------------
Last Update Date | 05/10/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5101 NW NEWARK LN
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34983-5369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-344-8482
-----------------------------------------------------
Fax | 772-344-8482
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5101 NW NEWARK LN
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34983-5369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-344-8482
-----------------------------------------------------
Fax | 772-344-8482
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. RODERICK GERMAINE DIXON SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 772-216-8314
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number | 229501
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------