Provider Demographics
NPI:1780606715
Name:BRANDON FACILITY OPERATIONS LLC
Entity type:Organization
Organization Name:BRANDON 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 1:701 VICTORIA ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-4100
Mailing Address - Country:US
Mailing Address - Phone:813-681-4220
Mailing Address - Fax:813-689-5685
Practice Address - Street 1:701 VICTORIA ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-4100
Practice Address - Country:US
Practice Address - Phone:813-681-4220
Practice Address - Fax:813-689-5685
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
FLSNF1577096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008037700Medicaid
FL031966000Medicaid
10-5520Medicare PIN
5911660001Medicare NSC