Provider Demographics
NPI:1083983720
Name:3001 PALM COAST PARKWAY OPERATIONS LLC
Entity Type:Organization
Organization Name:3001 PALM COAST PARKWAY OPERATIONS LLC
Other - Org Name:GRAND OAKS HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:USSERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-571-1550
Mailing Address - Street 1:3001 PALM COAST PKWY SE
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8209
Mailing Address - Country:US
Mailing Address - Phone:386-446-6060
Mailing Address - Fax:386-446-6033
Practice Address - Street 1:3001 PALM COAST PKWY SE
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8209
Practice Address - Country:US
Practice Address - Phone:386-446-6060
Practice Address - Fax:386-446-6033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF130470968314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004386400Medicaid
105952Medicare Oscar/Certification