Basic Information
Provider Information | |||||||||
NPI: | 1295064384 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KND DEVELOPMENT 59, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | 4876 KH HOLLYWOOD | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 680 S 4TH ST | ||||||||
Address2: |   | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402022407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5025967300 | ||||||||
FaxNumber: | 8335019731 | ||||||||
Practice Location | |||||||||
Address1: | 1859 VAN BUREN ST | ||||||||
Address2: |   | ||||||||
City: | HOLLYWOOD | ||||||||
State: | FL | ||||||||
PostalCode: | 330205127 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9549209000 | ||||||||
FaxNumber: | 5025964150 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/18/2009 | ||||||||
LastUpdateDate: | 07/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FISHER | ||||||||
AuthorizedOfficialFirstName: | LINDA | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | DVP REVENUE CYCLE | ||||||||
AuthorizedOfficialTelephone: | 5025967358 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | KINDRED HEALTHCARE, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | DL118B | 01 | FL | MEDICARE | OTHER |