Healthcare Provider Details

I. General information

NPI: 1669741302
Provider Name (Legal Business Name): 11565 HARTS ROAD OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2011
Last Update Date: 09/13/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11565 HARTS RD
JACKSONVILLE FL
32218-3777
US

IV. Provider business mailing address

11565 HARTS RD
JACKSONVILLE FL
32218-3777
US

V. Phone/Fax

Practice location:
  • Phone: 904-751-1834
  • Fax: 904-751-0272
Mailing address:
  • Phone: 904-751-1834
  • Fax: 904-751-0272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF15640961
License Number StateFL

VIII. Authorized Official

Name: MIRIAM C. PASTOR
Title or Position: MANAGER
Credential:
Phone: 786-457-2383