Healthcare Provider Details

I. General information

NPI: 1497983936
Provider Name (Legal Business Name): KINDRED DEVELOPMENT 17, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 W NASA BLVD
MELBOURNE FL
32901-1815
US

IV. Provider business mailing address

765 W NASA BLVD
MELBOURNE FL
32901-1815
US

V. Phone/Fax

Practice location:
  • Phone: 321-733-5725
  • Fax: 321-733-5725
Mailing address:
  • Phone: 321-733-5725
  • Fax: 321-733-5799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License Number4501
License Number StateFL

VIII. Authorized Official

Name: JOHNETTA TRAYLOR
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 502-596-6063