MEDICARE: 4641 OLD CANOE CREEK ROAD 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	SNF16340962	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	:	1528337276
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	4641 OLD CANOE CREEK ROAD OPERATIONS LLC

Provider Business Mailing Address
First Line	:	4641 OLD CANOE CREEK RD
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-1550
Country	:	US
Telephone Number	:	407-892-7344
Fax Number	:	407-892-5244

Provider Business Practice Location Address
First Line	:	4641 OLD CANOE CREEK RD
Second Line	:
City	:	SAINT CLOUD
State	:	FL
Zip	:	34769-1550
Country	:	US
Telephone Number	:	407-892-7344
Fax Number	:	407-892-5244

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

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

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