=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669986048
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KENNY CARE ASSISTED LIVING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2017
-----------------------------------------------------
Last Update Date | 11/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1614 JAMES GOOD LN
-----------------------------------------------------
City | GARLAND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75043-1123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-607-8841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4239 MCKINNEY AVE APT 105
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75205-4507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-607-8841
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | KENNETH INSAIDOO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-607-8841
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------