Healthcare Provider Details

I. General information

NPI: 1508638834
Provider Name (Legal Business Name): 12170 CORTEZ BLVD OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12170 CORTEZ BLVD
BROOKSVILLE FL
34613-5578
US

IV. Provider business mailing address

12170 CORTEZ BLVD
BROOKSVILLE FL
34613-5578
US

V. Phone/Fax

Practice location:
  • Phone: 352-597-5100
  • Fax: 352-597-5020
Mailing address:
  • Phone: 352-597-5100
  • Fax: 352-597-5020

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: NATHAN FREUND
Title or Position: MANAGER
Credential:
Phone: 732-730-7480