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General NPI Number Information
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NPI Number | 1336418102
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Entity Type | Organization
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Legal Business Name | 195 MATTIE M. KELLY BOULEVARD OPERATIONS LLC
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Dates
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Enumeration Date | 12/22/2011
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Last Update Date | 11/27/2023
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Provider Practice Location Address
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Address Line | 195 MATTIE M KELLY BLVD
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City | DESTIN
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State | FL
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Zip | 32541-2811
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Country | US
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Telephone | 850-654-4588
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Fax | 850-654-3944
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Provider Business Mailing Address
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Address Line | 195 MATTIE M KELLY BLVD
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City | DESTIN
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State | FL
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Zip | 32541-2811
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Country | US
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Telephone | 850-654-4588
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Fax | 850-654-3944
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Authorized Official
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Title or Position | VP
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Name | KENNETH USSERY
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Credential |
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Telephone | 407-571-1550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | SNF16210961
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License Number State | FL
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