Provider Demographics
NPI:1508349838
Name:KING, EVITA (STANDARD CARE ALF)
Entity Type:Individual
Prefix:MRS
First Name:EVITA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:STANDARD CARE ALF
Other - Prefix:MRS
Other - First Name:RITA
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CAMELOT COURT
Mailing Address - Street 1:2233 MCKINLEY ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-3054
Mailing Address - Country:US
Mailing Address - Phone:954-922-0808
Mailing Address - Fax:954-922-0882
Practice Address - Street 1:2233 MCKINLEY ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-3054
Practice Address - Country:US
Practice Address - Phone:954-922-0808
Practice Address - Fax:954-922-0882
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-12
Last Update Date:2018-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL7096385H00000X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100938600Medicaid