Provider Demographics
NPI:1063781839
Name:3825 COUNTRYSIDE BOULEVARD OPERATIONS LLC
Entity type:Organization
Organization Name:3825 COUNTRYSIDE BOULEVARD 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 1:3825 COUNTRYSIDE BLVD N
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34684-4928
Mailing Address - Country:US
Mailing Address - Phone:727-784-2848
Mailing Address - Fax:727-781-1402
Practice Address - Street 1:3825 COUNTRYSIDE BLVD N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-4928
Practice Address - Country:US
Practice Address - Phone:727-784-2848
Practice Address - Fax:727-781-1402
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
FLSNF11060962314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004387200Medicaid
105587Medicare Oscar/Certification