Provider Demographics
NPI:1326487281
Name:CTK PROPERTIES, LLC
Entity Type:Organization
Organization Name:CTK PROPERTIES, LLC
Other - Org Name:KIVA OF MOUNT DORA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-383-5005
Mailing Address - Street 1:505 E 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-4937
Mailing Address - Country:US
Mailing Address - Phone:352-383-5005
Mailing Address - Fax:
Practice Address - Street 1:505 E 9TH AVE
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-4937
Practice Address - Country:US
Practice Address - Phone:352-383-5005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL7959310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL689402000Medicaid