Provider Demographics
NPI:1376812016
Name:626 NORTH TYNDALL PARKWAY OPERATIONS LLC
Entity Type:Organization
Organization Name:626 NORTH TYNDALL PARKWAY OPERATIONS LLC
Other - Org Name:EMERALD SHORES HEALTH AND REHABILITATION
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 1:626 N TYNDALL PKWY
Mailing Address - Street 2:
Mailing Address - City:CALLAWAY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-6132
Mailing Address - Country:US
Mailing Address - Phone:850-871-6363
Mailing Address - Fax:850-871-6367
Practice Address - Street 1:626 N TYNDALL PKWY
Practice Address - Street 2:
Practice Address - City:CALLAWAY
Practice Address - State:FL
Practice Address - Zip Code:32404-6132
Practice Address - Country:US
Practice Address - Phone:850-871-6363
Practice Address - Fax:850-871-6367
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
FLSNF1292096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006097200Medicaid
FL006097200Medicaid