Basic Information
| Provider Information | |||||||||
| NPI: | 1841886959 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KINDRED DEVELOPMENT 17, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KINDRED HOSPITAL MELBOURNE (ACUTE REHAB UNIT) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 765 W NASA BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329011815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217335725 | ||||||||
| FaxNumber: | 3217335799 | ||||||||
| Practice Location | |||||||||
| Address1: | 765 W NASA BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329011815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217335725 | ||||||||
| FaxNumber: | 3217335799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2020 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TEAGUE | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT, CORPORATE SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 6292535121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 4501 | 01 | FL | HOSPITAL LICENSE | OTHER |