Healthcare Provider Details

I. General information

NPI: 1851660500
Provider Name (Legal Business Name): 207 MARSHALL DRIVE 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: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 MARSHALL DR
PERRY FL
32347-1835
US

IV. Provider business mailing address

207 MARSHALL DR
PERRY FL
32347-1835
US

V. Phone/Fax

Practice location:
  • Phone: 850-584-6334
  • Fax: 850-838-1801
Mailing address:
  • Phone: 850-584-6334
  • Fax: 850-838-1801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1436096
License Number StateFL

VIII. Authorized Official

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