Healthcare Provider Details

I. General information

NPI: 1821367608
Provider Name (Legal Business Name): 702 SOUTH KINGS AVENUE OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 11/27/2023
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 S KINGS AVE
BRANDON FL
33511-5925
US

IV. Provider business mailing address

702 S KINGS AVE
BRANDON FL
33511-5925
US

V. Phone/Fax

Practice location:
  • Phone: 813-651-1818
  • Fax: 813-654-4252
Mailing address:
  • Phone: 813-651-1818
  • Fax: 813-654-4252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1088096
License Number StateFL

VIII. Authorized Official

Name: KENNETH USSERY
Title or Position: VP
Credential:
Phone: 407-571-1550