Provider Demographics
NPI:1699114066
Name:ELIDA M. REYES-KERR
Entity type:Organization
Organization Name:ELIDA M. REYES-KERR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:REYES-KERR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-984-7568
Mailing Address - Street 1:1351 STEELE RD SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-5332
Mailing Address - Country:US
Mailing Address - Phone:321-989-7568
Mailing Address - Fax:
Practice Address - Street 1:1351 STEELE RD SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-5332
Practice Address - Country:US
Practice Address - Phone:321-989-7568
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12126310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005613700Medicaid