Provider Demographics
NPI:1184342867
Name:FKP FORT WALTON BEACH SENIOR LIVING TENANT LLC
Entity type:Organization
Organization Name:FKP FORT WALTON BEACH SENIOR LIVING TENANT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:AYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-292-1513
Mailing Address - Street 1:2000 PRINCIPAL LN
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6636
Mailing Address - Country:US
Mailing Address - Phone:850-243-7735
Mailing Address - Fax:
Practice Address - Street 1:2000 PRINCIPAL LN
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6636
Practice Address - Country:US
Practice Address - Phone:850-243-7735
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0000000Medicaid