Provider Demographics
NPI:1710419205
Name:FRANCISCO, KEYLA (BUSINESS OWNER)
Entity Type:Individual
Prefix:
First Name:KEYLA
Middle Name:
Last Name:FRANCISCO
Suffix:
Gender:F
Credentials:BUSINESS OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1631 PINEBERRY ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-3432
Mailing Address - Country:US
Mailing Address - Phone:863-709-4454
Mailing Address - Fax:
Practice Address - Street 1:1631 PINEBERRY ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-3432
Practice Address - Country:US
Practice Address - Phone:863-709-4454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL192181171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
192181OtherBUSINESS LICENCE