Provider Demographics
NPI:1013934660
Name:COREY KARE HOME & COMMUNITY SUPPORT SERVICES, LLC
Entity Type:Organization
Organization Name:COREY KARE HOME & COMMUNITY SUPPORT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:GERMAINE
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:772-216-8314
Mailing Address - Street 1:5101 NW NEWARK LN
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-5369
Mailing Address - Country:US
Mailing Address - Phone:772-344-8482
Mailing Address - Fax:772-344-8482
Practice Address - Street 1:5101 NW NEWARK LN
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-5369
Practice Address - Country:US
Practice Address - Phone:772-344-8482
Practice Address - Fax:772-344-8482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2009-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL229501251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL688595198Medicaid
FL688595196Medicaid