MEDICARE: KALEB'S ROOM LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	253Z00000X	In Home Supportive Care Agency
2	385H00000X	Respite Care
3	3747P1801X	Personal Care Attendant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144194630
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KALEB'S ROOM LLC

Provider Business Mailing Address
First Line	:	9428 BAYMEADOWS RD STE 502
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-7973
Country	:	US
Telephone Number	:	904-649-2985
Fax Number	:	904-934-1012

Provider Business Practice Location Address
First Line	:	12172 HAYDEN LAKES CIR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-9068
Country	:	US
Telephone Number	:	904-649-2985
Fax Number	:	904-934-1012

Authorized Official
Title or Position	:	OWNER
Name	:	LASHANDER SIMMONS
Credential	:	LPN
Telephone Number	:	904-649-2985

Provider Enumeration Date	:	09/30/2025
Last Update Date	:	09/30/2025

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Directions to “KALEB'S ROOM LLC ” Practice Location

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