Provider Demographics
NPI:1811317605
Name:ORANGE PARK MGT, LLC
Entity type:Organization
Organization Name:ORANGE PARK MGT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:B
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-578-6599
Mailing Address - Street 1:833 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4701
Mailing Address - Country:US
Mailing Address - Phone:904-269-2610
Mailing Address - Fax:904-269-0873
Practice Address - Street 1:833 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4701
Practice Address - Country:US
Practice Address - Phone:904-269-2610
Practice Address - Fax:904-269-0873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1237096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013081700Medicaid
FL105586Medicare Oscar/Certification
FL013081700Medicaid