Healthcare Provider Details

I. General information

NPI: 1750650610
Provider Name (Legal Business Name): 6414 13TH ROAD SOUTH OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 11/27/2023
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6414 13TH ROAD S
W. PALM BEACH FL
33415-1401
US

IV. Provider business mailing address

6414 13TH ROAD S
W. PALM BEACH FL
33415-1401
US

V. Phone/Fax

Practice location:
  • Phone: 561-478-9900
  • Fax: 561-478-5067
Mailing address:
  • Phone: 561-478-9900
  • Fax: 561-478-5067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF13390962
License Number StateFL

VIII. Authorized Official

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