=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053104430
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORA KAYYS HOME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2025
-----------------------------------------------------
Last Update Date | 06/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 610 MARSHALL ST STE 701
-----------------------------------------------------
City | SHREVEPORT
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71101-3660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-286-2043
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 308 W JOSIE LN
-----------------------------------------------------
City | HAUGHTON
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71037-3700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-286-2043
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | KHALIAH SHILEEN COOK
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 318-286-2043
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------