Provider Demographics
NPI:1568731206
Name:9355 SAN JOSE BOULEVARD OPERATIONS LLC
Entity Type:Organization
Organization Name:9355 SAN JOSE BOULEVARD OPERATIONS LLC
Other - Org Name:SAN JOSE 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 1:9355 SAN JOSE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-5503
Mailing Address - Country:US
Mailing Address - Phone:904-739-0877
Mailing Address - Fax:904-448-9253
Practice Address - Street 1:9355 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-5503
Practice Address - Country:US
Practice Address - Phone:904-739-0877
Practice Address - Fax:904-448-9253
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
FLSNF1047096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006110200Medicaid
105531Medicare Oscar/Certification