Provider Demographics
NPI:1356492425
Name:KEYWEST CENTER INC.
Entity Type:Organization
Organization Name:KEYWEST CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-682-9392
Mailing Address - Street 1:1722 ATHENS AVE.
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-4312
Mailing Address - Country:US
Mailing Address - Phone:919-682-9392
Mailing Address - Fax:919-683-1774
Practice Address - Street 1:1722 ATHENS AVE.
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-4312
Practice Address - Country:US
Practice Address - Phone:919-682-9392
Practice Address - Fax:919-683-1774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-032-049315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406548Medicaid