626 North Tyndall Parkway Operations LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

License

SNF1292096 Issued in FL

Legal business name

626 NORTH TYNDALL PARKWAY OPERATIONS LLC

Doing business as

Emerald Shores Health and Rehabilitation

Practice address

626 N Tyndall Pkwy
Callaway, FL 32404-6132

Phone

(850) 871-6363

Fax

(850) 871-6367

NPI assigned

Dec 27, 2011

Last updated

Nov 27, 2023By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Kenneth Ussery

Title

VP

Phone

(407) 571-1550

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Emerald Shores Health and Rehabilitation Doing business as

Electronic endpoints 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1324944000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1701043200000",
    "number": "1376812016",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "626 N TYNDALL PKWY",
            "city": "CALLAWAY",
            "state": "FL",
            "postal_code": "324046132",
            "telephone_number": "850-871-6363",
            "fax_number": "850-871-6367"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "626 N TYNDALL PKWY",
            "city": "CALLAWAY",
            "state": "FL",
            "postal_code": "324046132",
            "telephone_number": "850-871-6363",
            "fax_number": "850-871-6367"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "626 NORTH TYNDALL PARKWAY OPERATIONS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-12-27",
        "last_updated": "2023-11-27",
        "certification_date": "2020-04-27",
        "status": "A",
        "authorized_official_last_name": "USSERY",
        "authorized_official_first_name": "KENNETH",
        "authorized_official_title_or_position": "VP",
        "authorized_official_telephone_number": "407-571-1550"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "FL",
            "license": "SNF1292096",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "006097200",
            "state": "FL"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://65.196.137.118:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRResponse_Service",
            "affiliation": "Y",
            "endpointDescription": "urn:oid:2.16.840.1.113883.3.5042",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "800 Concourse Pkwy S Ste 200",
            "city": "Maitland",
            "state": "FL",
            "country_code": "US",
            "postal_code": "327516148",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Emerald Shores Health and Rehabilitation",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Emerald Shores Health and Rehabilitation",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• 626 N Tyndall Pkwy Opco LLC (Aviata at Emerald Shores)
• Sylvia Lynn Abercrombie-Broad
• Rebecca Barrett
• Allison Blackstock
• Mary Virginia Blue, OTR/L
• Lance Mathew Campbell, DHSC, MSCPT, MTC

• Skilled Nursing Facility in Callaway, FL
• Providers in Callaway, FL by specialty
• Skilled Nursing Facility in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 27, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.