Provider Demographics
NPI:1265902787
Name:CRP/FDG WEST KENDALL SL OWNER, L.L.C.
Entity type:Organization
Organization Name:CRP/FDG WEST KENDALL SL OWNER, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-797-9482
Mailing Address - Street 1:1001 PENNSYLVANIA AVE NW STE 220
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20004-2525
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9355 SW 158TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-5872
Practice Address - Country:US
Practice Address - Phone:786-878-5140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-27
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility