Provider Demographics
NPI:1427003763
Name:KISSIMMEE HEALTH CARE ASSOCIATES LLC
Entity Type:Organization
Organization Name:KISSIMMEE HEALTH CARE ASSOCIATES LLC
Other - Org Name:KEYSTONE REHABILITATION AND HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TYRUS
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-847-2854
Mailing Address - Street 1:1120 W DONEGAN AVE
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-2247
Mailing Address - Country:US
Mailing Address - Phone:407-847-2854
Mailing Address - Fax:407-994-4184
Practice Address - Street 1:1120 W DONEGAN AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2247
Practice Address - Country:US
Practice Address - Phone:407-847-2854
Practice Address - Fax:407-994-4184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL130471039314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031756000Medicaid
106074Medicare Oscar/Certification