Basic Information
| Provider Information | |||||||||
| NPI: | 1063805018 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEARTLAND OF KENDALL FL, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEARTLAND HEALTH CARE CENTER - KENDALL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SUMMIT ST | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436042615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192525500 | ||||||||
| FaxNumber: | 8773859446 | ||||||||
| Practice Location | |||||||||
| Address1: | 9400 SW 137TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331861434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3053858290 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2015 | ||||||||
| LastUpdateDate: | 06/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4192525734 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AL7307 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 012206-00 | 01 | FL | MEDICAID WAIVER | OTHER |