MEDICARE: J2112, 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

General Provider Information

NPI Number	:	1538884259
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J2112, LLC

Provider Business Mailing Address
First Line	:	200 CLEARWATER LARGO RD S
Second Line	:
City	:	LARGO
State	:	FL
Zip	:	33770-3235
Country	:	US
Telephone Number	:	727-489-0857
Fax Number	:

Provider Business Practice Location Address
First Line	:	11300 110TH AVE
Second Line	:
City	:	SEMINOLE
State	:	FL
Zip	:	33778-3711
Country	:	US
Telephone Number	:	727-391-9986
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	KEVIN RYAN ROCKEFELLER
Credential	:
Telephone Number	:	904-422-5231

Provider Enumeration Date	:	10/05/2022
Last Update Date	:	10/05/2022

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Directions to “J2112, LLC ” Practice Location

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