MEDICARE: 195 MATTIE M. KELLY BOULEVARD OPERATIONS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	SNF16210961	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336418102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	195 MATTIE M. KELLY BOULEVARD OPERATIONS LLC

Provider Business Mailing Address
First Line	:	195 MATTIE M KELLY BLVD
Second Line	:
City	:	DESTIN
State	:	FL
Zip	:	32541-2811
Country	:	US
Telephone Number	:	850-654-4588
Fax Number	:	850-654-3944

Provider Business Practice Location Address
First Line	:	195 MATTIE M KELLY BLVD
Second Line	:
City	:	DESTIN
State	:	FL
Zip	:	32541-2811
Country	:	US
Telephone Number	:	850-654-4588
Fax Number	:	850-654-3944

Authorized Official
Title or Position	:	VP
Name	:	KENNETH USSERY
Credential	:
Telephone Number	:	407-571-1550

Provider Enumeration Date	:	12/22/2011
Last Update Date	:	11/27/2023

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