Healthcare Provider Details

I. General information

NPI: 1083983720
Provider Name (Legal Business Name): 3001 PALM COAST PARKWAY OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2011
Last Update Date: 11/27/2023
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 PALM COAST PKWY SE
PALM COAST FL
32137-8209
US

IV. Provider business mailing address

3001 PALM COAST PKWY SE
PALM COAST FL
32137-8209
US

V. Phone/Fax

Practice location:
  • Phone: 386-446-6060
  • Fax: 386-446-6033
Mailing address:
  • Phone: 386-446-6060
  • Fax: 386-446-6033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF130470968
License Number StateFL

VIII. Authorized Official

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