Healthcare Provider Details

I. General information

NPI: 1528337276
Provider Name (Legal Business Name): 4641 OLD CANOE CREEK ROAD 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

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 NumberSNF16340962
License Number StateFL

VIII. Authorized Official

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