Provider Demographics
NPI:1114922572
Name:M-K OF NORTH PORT L L C
Entity type:Organization
Organization Name:M-K OF NORTH PORT L L C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-426-8411
Mailing Address - Street 1:6940 OUTREACH WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH PORT
Mailing Address - State:FL
Mailing Address - Zip Code:34287-3405
Mailing Address - Country:US
Mailing Address - Phone:941-426-8411
Mailing Address - Fax:941-423-1572
Practice Address - Street 1:6940 OUTREACH WAY
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-3405
Practice Address - Country:US
Practice Address - Phone:941-426-8411
Practice Address - Fax:941-423-1572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1455095314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022505300Medicaid
FL105523Medicare Oscar/Certification