Provider Demographics
NPI:1154328102
Name:M-K OF HAINES CITY L L C
Entity Type:Organization
Organization Name:M-K OF HAINES CITY L L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-422-8656
Mailing Address - Street 1:409 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-5603
Mailing Address - Country:US
Mailing Address - Phone:863-422-8656
Mailing Address - Fax:863-422-8008
Practice Address - Street 1:409 S 10TH ST
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-5603
Practice Address - Country:US
Practice Address - Phone:863-422-8656
Practice Address - Fax:863-422-8008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-06
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1190095314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022434100Medicaid
FL022434100Medicaid