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General NPI Number Information
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NPI Number | 1457231003
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Entity Type | Organization
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Legal Business Name | KETTLY HOUSE LLC
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Dates
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Enumeration Date | 09/04/2025
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Last Update Date | 09/04/2025
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Provider Practice Location Address
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Address Line | 2191 NW 74TH AVE
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City | SUNRISE
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State | FL
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Zip | 33313-3855
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Country | US
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Telephone | 954-546-0667
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Fax |
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Provider Business Mailing Address
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Address Line | 2191 NW 74TH AVE
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City | SUNRISE
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State | FL
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Zip | 33313-3855
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Country | US
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Telephone | 954-546-0667
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | KETTLY DERIVAL
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Credential | RN
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Telephone | 954-546-0667
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 163WC1500X
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Taxonomy Name | Community Health Registered Nurse
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License Number |
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License Number State |
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