Provider Demographics
NPI:1629582440
Name:FOUR HEARTS
Entity Type:Organization
Organization Name:FOUR HEARTS
Other - Org Name:FOUR HEARTS HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEWEL
Authorized Official - Middle Name:ELOIS
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-876-1541
Mailing Address - Street 1:PO BOX 10452
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33419-0452
Mailing Address - Country:US
Mailing Address - Phone:561-876-1541
Mailing Address - Fax:
Practice Address - Street 1:462 W 14TH ST
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404
Practice Address - Country:US
Practice Address - Phone:561-876-1541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-01
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL234977251E00000X
310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020574100Medicaid