Provider Demographics
NPI:1982155206
Name:FOUR HEARTS COMPANION SERVICES LLC
Entity type:Organization
Organization Name:FOUR HEARTS COMPANION SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/ PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEWEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-876-1541
Mailing Address - Street 1:PO BOX 10452
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33419-0452
Mailing Address - Country:US
Mailing Address - Phone:561-876-1541
Mailing Address - Fax:
Practice Address - Street 1:462 W 14TH ST
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-6810
Practice Address - Country:US
Practice Address - Phone:561-876-1541
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-21
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL253Z00000X
385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019662800Medicaid