Provider Demographics
NPI:1821367608
Name:702 SOUTH KINGS AVENUE OPERATIONS LLC
Entity Type:Organization
Organization Name:702 SOUTH KINGS AVENUE OPERATIONS LLC
Other - Org Name:CENTRAL PARK HEALTHCARE 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 1:702 S KINGS AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5925
Mailing Address - Country:US
Mailing Address - Phone:813-651-1818
Mailing Address - Fax:813-654-4252
Practice Address - Street 1:702 S KINGS AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5925
Practice Address - Country:US
Practice Address - Phone:813-651-1818
Practice Address - Fax:813-654-4252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-22
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1088096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004385600Medicaid
105718Medicare Oscar/Certification