Provider Demographics
NPI:1275814121
Name:KYDD AT HEART ADULT FAMILY HOME LLC
Entity Type:Organization
Organization Name:KYDD AT HEART ADULT FAMILY HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KYDD
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:360-790-2863
Mailing Address - Street 1:4810 18TH AVE SE
Mailing Address - Street 2:STE 2
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-2652
Mailing Address - Country:US
Mailing Address - Phone:360-790-2863
Mailing Address - Fax:
Practice Address - Street 1:4810 18TH AVE SE
Practice Address - Street 2:STE 2
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-2652
Practice Address - Country:US
Practice Address - Phone:360-790-2863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA752014310400000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No385H00000XRespite Care FacilityRespite Care