Provider Demographics
NPI:1700176732
Name:KESHA HEALTH CARE SERVICE,LLC
Entity Type:Organization
Organization Name:KESHA HEALTH CARE SERVICE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAKESHA
Authorized Official - Middle Name:SHONEASE
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-595-6212
Mailing Address - Street 1:135 MANSEAU DR
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-1719
Mailing Address - Country:US
Mailing Address - Phone:863-595-6212
Mailing Address - Fax:863-875-4742
Practice Address - Street 1:135 MANSEAU DR
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-1719
Practice Address - Country:US
Practice Address - Phone:863-595-6212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL001447200305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003167300Medicaid
FL001447200Medicaid
FL001447201Medicaid