Provider Demographics
NPI:1649293622
Name:MELBOURNE FACILITY OPERATIONS LLC
Entity type:Organization
Organization Name:MELBOURNE FACILITY OPERATIONS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:3033 SARNO RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-7229
Mailing Address - Country:US
Mailing Address - Phone:321-255-9200
Mailing Address - Fax:321-255-9213
Practice Address - Street 1:3033 SARNO RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32934-7229
Practice Address - Country:US
Practice Address - Phone:321-255-9200
Practice Address - Fax:321-255-9213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF16220961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008039400Medicaid
FL008039400Medicaid
FL008039400Medicaid
FL031952000Medicaid