Provider Demographics
NPI:1144787607
Name:PROFESSIONAL REGISTERED SERVICES, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL REGISTERED SERVICES, LLC
Other - Org Name:DOMINIQUE REGISTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MS
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:REGISTER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:321-239-7606
Mailing Address - Street 1:3207 TRADEWINDS TRL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32805-5851
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3207 TRADEWINDS TRL
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-5851
Practice Address - Country:US
Practice Address - Phone:321-239-7606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-20
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No251S00000XAgenciesCommunity/Behavioral Health
No253J00000XAgenciesFoster Care Agency
No253Z00000XAgenciesIn Home Supportive Care
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104607300Medicaid
FL024196800Medicaid