Healthcare Provider Details

I. General information

NPI: 1780363952
Provider Name (Legal Business Name): PARK BOULEVARD OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2023
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9393 PARK BLVD
SEMINOLE FL
33777-4140
US

IV. Provider business mailing address

9393 PARK BLVD
SEMINOLE FL
33777-4140
US

V. Phone/Fax

Practice location:
  • Phone: 727-391-2200
  • Fax: 727-319-2611
Mailing address:
  • Phone: 727-391-2200
  • Fax: 727-319-2611

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