Basic Information
| Provider Information | |||||||||
| NPI: | 1669741302 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 11565 HARTS ROAD OPERATIONS LLC | ||||||||
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| OtherOrganizationName: | HARTS HARBOR HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11565 HARTS RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322183777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047511834 | ||||||||
| FaxNumber: | 9047510272 | ||||||||
| Practice Location | |||||||||
| Address1: | 11565 HARTS RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322183777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047511834 | ||||||||
| FaxNumber: | 9047510272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2011 | ||||||||
| LastUpdateDate: | 04/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | USSERY | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 4075711550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | SNF15640961 | FL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 004386500 | 05 | FL | MEDICAID |