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General NPI Number Information
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NPI Number | 1700176732
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Entity Type | Organization
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Legal Business Name | KESHA HEALTH CARE SERVICE,LLC
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Dates
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Enumeration Date | 04/11/2011
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Last Update Date | 04/11/2011
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Provider Practice Location Address
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Address Line | 135 MANSEAU DR
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City | WINTER HAVEN
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State | FL
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Zip | 33880-1719
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Country | US
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Telephone | 863-595-6212
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Fax |
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Provider Business Mailing Address
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Address Line | 135 MANSEAU DR
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City | WINTER HAVEN
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State | FL
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Zip | 33880-1719
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Country | US
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Telephone | 863-595-6212
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Fax | 863-875-4742
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Authorized Official
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Title or Position | OWNER
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Name | NAKESHA SHONEASE YOUNG
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Credential |
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Telephone | 863-595-6212
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 001447200
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License Number State | FL
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