Healthcare Provider Details

I. General information

NPI: 1194597427
Provider Name (Legal Business Name): 541 OLD CANOE CREEK RD 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

4641 OLD CANOE CREEK RD
SAINT CLOUD FL
34769-1550
US

IV. Provider business mailing address

4641 OLD CANOE CREEK RD
SAINT CLOUD FL
34769-1550
US

V. Phone/Fax

Practice location:
  • Phone: 407-892-7344
  • Fax: 407-892-5244
Mailing address:
  • Phone: 407-892-7344
  • Fax: 407-892-5244

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