MEDICARE: KISSLEE, 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

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	:	1912477696
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KISSLEE, LLC

Provider Business Mailing Address
First Line	:	2720 SW 6TH CT
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-2139
Country	:	US
Telephone Number	:	954-523-1543
Fax Number	:

Provider Business Practice Location Address
First Line	:	2720 SW 6TH CT
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-2139
Country	:	US
Telephone Number	:	954-530-3360
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. JASON KISSOONLAL
Credential	:
Telephone Number	:	954-523-1543

Provider Enumeration Date	:	11/26/2018
Last Update Date	:	08/26/2020

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Directions to “KISSLEE, LLC ” Practice Location

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