Healthcare Provider Details

I. General information

NPI: 1003569385
Provider Name (Legal Business Name): BLOUNTSTOWN FL OPERATOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2022
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16690 SW CHIPOLA RD
BLOUNTSTOWN FL
32424-1953
US

IV. Provider business mailing address

16690 SW CHIPOLA RD
BLOUNTSTOWN FL
32424-1953
US

V. Phone/Fax

Practice location:
  • Phone: 917-295-1882
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: ROBERT KOLMAN
Title or Position: OPERATOR
Credential: LNHA
Phone: 917-295-1882