=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215794250
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KM PLATINUM HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2024
-----------------------------------------------------
Last Update Date | 03/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3436 AVENUE O
-----------------------------------------------------
City | RIVIERA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33404-2928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-530-4287
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15533 SW 107TH CT
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33157-1349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-801-6516
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | KIMBERLY ANDREA MATTHEWS
-----------------------------------------------------
Credential | REGISTERED NURSE
-----------------------------------------------------
Telephone | 305-801-8616
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253J00000X
-----------------------------------------------------
Taxonomy Name | Foster Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------