MEDICARE: KONA 66 LLC

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	310400000X	Assisted Living Facility	AL13197	FL

General Provider Information

NPI Number	:	1841777919
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KONA 66 LLC

Provider Business Mailing Address
First Line	:	8447 DUNHAM STATION DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-3339
Country	:	US
Telephone Number	:	813-967-3808
Fax Number	:	813-435-2244

Provider Business Practice Location Address
First Line	:	3200 66TH ST N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33710-1511
Country	:	US
Telephone Number	:	727-914-3012
Fax Number	:	727-914-3013

Authorized Official
Title or Position	:	OWNER
Name	:	CHIRAG AMIN
Credential	:	RPH
Telephone Number	:	813-967-3808

Provider Enumeration Date	:	07/23/2018
Last Update Date	:	07/23/2018

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