MEDICARE: FKPPEC4, INC.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3140N1450X	Pediatric Skilled Nursing Facility

General Provider Information

NPI Number	:	1255083424
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FKPPEC4, INC.

Provider Business Mailing Address
First Line	:	6515 TAFT ST
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33024-4008
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7202 W COLONIAL DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32818-6743
Country	:	US
Telephone Number	:	866-635-7732
Fax Number	:

Authorized Official
Title or Position	:	CHIEF COMPLIANCE OFFICER
Name	:	JONATHAN DAVID CARVAJAL
Credential	:	ESQ
Telephone Number	:	305-796-5103

Provider Enumeration Date	:	01/19/2022
Last Update Date	:	01/19/2022

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Directions to “FKPPEC4, INC. ” Practice Location

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