Provider Demographics
NPI:1952997900
Name:KEYSTONE SUPPORT SERVICES LLC
Entity Type:Organization
Organization Name:KEYSTONE SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-658-1016
Mailing Address - Street 1:10135 GATE PKWY N APT 1516
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-8267
Mailing Address - Country:US
Mailing Address - Phone:954-224-8216
Mailing Address - Fax:
Practice Address - Street 1:10135 GATE PKWY N APT 1516
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-8267
Practice Address - Country:US
Practice Address - Phone:954-224-8216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-14
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities