Healthcare Provider Details

I. General information

NPI: 1912276791
Provider Name (Legal Business Name): 1465 OAKFIELD DRIVE 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

1465 OAKFIELD DR
BRANDON FL
33511-4854
US

IV. Provider business mailing address

1465 OAKFIELD DR
BRANDON FL
33511-4854
US

V. Phone/Fax

Practice location:
  • Phone: 813-655-0404
  • Fax: 813-654-9589
Mailing address:
  • Phone: 813-655-0404
  • Fax: 813-654-9589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF130470969
License Number StateFL

VIII. Authorized Official

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