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General NPI Number Information
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NPI Number | 1821367608
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Entity Type | Organization
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Legal Business Name | 702 SOUTH KINGS AVENUE 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 | 702 S KINGS AVE
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City | BRANDON
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State | FL
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Zip | 33511-5925
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Country | US
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Telephone | 813-651-1818
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Fax | 813-654-4252
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Provider Business Mailing Address
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Address Line | 702 S KINGS AVE
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City | BRANDON
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State | FL
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Zip | 33511-5925
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Country | US
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Telephone | 813-651-1818
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Fax | 813-654-4252
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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 | SNF1088096
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License Number State | FL
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