Provider Demographics
NPI:1417470659
Name:PORT ROYAL HOME HEALTH CARE INC
Entity Type:Organization
Organization Name:PORT ROYAL HOME HEALTH CARE INC
Other - Org Name:MANDEVILLE QUALITY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KRISTO-JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-832-9385
Mailing Address - Street 1:111 NW 183RD ST STE 318B
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-4537
Mailing Address - Country:US
Mailing Address - Phone:305-832-9385
Mailing Address - Fax:786-440-5046
Practice Address - Street 1:111 NW 183RD ST STE 318B
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169-4537
Practice Address - Country:US
Practice Address - Phone:305-832-9385
Practice Address - Fax:786-440-5046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-19
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Single Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111478500Medicaid