Healthcare Provider Details

I. General information

NPI: 1396021077
Provider Name (Legal Business Name): BLOUNTSTOWN REHABILITATION CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2011
Last Update Date: 09/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17884 NE CROZIER ST
BLOUNTSTOWN FL
32424-1050
US

IV. Provider business mailing address

5887 GLENRIDGE DR NE
ATLANTA GA
30328-5574
US

V. Phone/Fax

Practice location:
  • Phone: 850-674-5464
  • Fax: 850-674-9384
Mailing address:
  • Phone: 404-574-2100
  • Fax: 404-574-2105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF12870961
License Number StateFL

VIII. Authorized Official

Name: MR. R. MARK CRONQUIST
Title or Position: MANAGER
Credential:
Phone: 404-574-2100