Provider Demographics
NPI:1700809662
Name:ST PETERSBURG FACILITY OPERATIONS, LLC
Entity Type:Organization
Organization Name:ST PETERSBURG FACILITY OPERATIONS, LLC
Other - Org Name:LIVING CENTER OF ST. PETERSBURG
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 1:9393 PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33777-4140
Mailing Address - Country:US
Mailing Address - Phone:727-391-2200
Mailing Address - Fax:727-319-2611
Practice Address - Street 1:9393 PARK BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33777-4140
Practice Address - Country:US
Practice Address - Phone:727-391-2200
Practice Address - Fax:727-319-2611
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
FLSNF1639096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008040900Medicaid
FL0319708-00Medicaid
10-5895Medicare PIN