Provider Demographics
NPI:1912562471
Name:KJCARES SUPORTIVE LIVING SERVICES
Entity type:Organization
Organization Name:KJCARES SUPORTIVE LIVING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-293-6757
Mailing Address - Street 1:20 FIRST STREET
Mailing Address - Street 2:APT 5
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084
Mailing Address - Country:US
Mailing Address - Phone:904-293-6757
Mailing Address - Fax:
Practice Address - Street 1:20 FIRST STREET
Practice Address - Street 2:APT 5
Practice Address - City:ST. AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084
Practice Address - Country:US
Practice Address - Phone:904-293-6757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty