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NPI Code Detail

MEDICARE: 15204 WEST COLONIAL DRIVE OPERATIONS LLC

MEDICARE: 15204 WEST COLONIAL DRIVE 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
1314000000XSkilled Nursing FacilitySNF1610096FL

Other Identifiers

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

General Provider Information

NPI Number : 1831468610
Entity Type Code : Organization
Provider Name (Legal Business Name) : 15204 WEST COLONIAL DRIVE OPERATIONS LLC
Provider Business Mailing Address
First Line : 15204 W COLONIAL DR
Second Line :
City : WINTER GARDEN
State : FL
Zip : 34787-6042
Country : US
Telephone Number : 407-877-2394
Fax Number : 407-877-6143
Provider Business Practice Location Address
First Line : 15204 W COLONIAL DR
Second Line :
City : WINTER GARDEN
State : FL
Zip : 34787-6042
Country : US
Telephone Number : 407-877-2394
Fax Number : 407-877-6143
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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