Healthcare Provider Details

I. General information

NPI: 1972193712
Provider Name (Legal Business Name): BLUE HERON HEALTH AND REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2021
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5085 EAGLESTON BOULEVARD
WESLEY CHAPEL FL
33544
US

IV. Provider business mailing address

1800 N WABASH RD
MARION IN
46952-1300
US

V. Phone/Fax

Practice location:
  • Phone: 813-454-0513
  • Fax:
Mailing address:
  • Phone: 765-664-5400
  • Fax: 765-664-5403

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: BETH R KLEE
Title or Position: EXECUTIVE ASSISTANT
Credential:
Phone: 765-664-5400