1215 Kingsley Ave Opco LLC – Skilled Nursing Facility

Key facts

NPI: 1598537813
Entity type: Organization (NPI type 2)
Primary specialty: Skilled Nursing Facility 314000000X
Legal business name: 1215 KINGSLEY AVE OPCO LLC
Practice address: 1215 Kingsley Ave
Orange Park, FL 32073-4631
Phone: (904) 269-8922
Fax: (904) 264-2253
NPI assigned: Oct 30, 2023
Organization subpart: No

Authorized official

Name: Nathan Freund
Title: Manager
Phone: (732) 730-7480

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Samira Khazravan, M.D. Geriatric Medicine (Internal Medicine) Physician · Jacksonville, FL · NPI 1942494984

CMS ownership ADP OF THE SNF · OPERATIONAL/MANAGERIAL CONTROL

Affiliated clinicians 1

Clinicians who list this facility as an affiliation in Medicare Care Compare.

Samira Khazravan, M.D. Geriatric Medicine (Internal Medicine) Physician · Jacksonville, FL · NPI 1942494984

Care Compare affiliation Nursing home

Medicare Care Compare: Nursing home

Listed as: Aviata at Orange Park CCN 105653
Overall star rating: ★★★★☆ 4 of 5
Health inspections: ★★★★☆ 4 of 5
Staffing: ★★☆☆☆ 2 of 5
Quality measures: ★★★☆☆ 3 of 5
Type: Medicare and Medicaid
Ownership: Non profit - Corporation
Certified: Jan 9, 1990
Medicare certification status: Active (Provider of Services file)
Certified beds: 120 · 110.8 residents per day on average
Chain: Aviata Health Group (50 facilities)

Source: Medicare Care Compare, processed Aug 1, 2026.

Laboratory certificates & supplier records

Name & address match These CMS records do not include an NPI. They are shown here because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA number	Laboratory	Certificate	Expires
10D0267192	Aviata at Orange Park 1215 Kingsley Ave, Orange Park, FL 32073	Certificate of waiver	Sep 29, 2027

Medicare participation

Medicare fee-for-service enrollment: Enrolled in FL

Skilled nursing facility certification: CCN 105653

Legal name: 1215 KINGSLEY AVE OPCO LLC
Doing business as: AVIATA AT ORANGE PARK
Certification status: Active
Provider type (POS): Nursing home – SNF/NF dual certification
Participating since: Jan 9, 1990
Last certification: Nov 9, 2023
Beds: 120
Ownership / control type: Nonprofit Corporation
Multi-facility organization: Aviata
Organization structure: LLC · Proprietary
Enrollment address: 1215 Kingsley Ave
Orange Park, FL 32073-4631
Nursing home name: AVIATA AT ORANGE PARK
Affiliated entity: AVIATA HEALTH GROUP

All disclosed owners & managing parties 9

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

Name	Role	Since	Share
Aspire MGT LLC Organization · Jackson, NJ LLC, For-profit, Chain home office	Adp of the SNF	Dec 1, 2023
Organization · Brooklyn, NY	Adp of the SNF	Jul 20, 2025
Organization · Springfield, MO	Adp of the SNF	Jul 20, 2025
Nochum Freund Individual	Corporate Officer Coo	Dec 1, 2023
Nochum Freund Individual	Operational/Managerial Control	Dec 1, 2023
1215 Kingsley Ave Opco Parent LLC Organization · Jackson, NJ Created for acquisition, LLC, For-profit, Owned by another organization or individual	Direct Ownership Interest	Dec 1, 2023	100%
Kalisha Rose Boese Individual	Operational/Managerial Control	Dec 4, 2024
Kalisha Rose Boese Individual	Adp of the SNF	Dec 4, 2024
Organization · Lakewood, NJ LLC	Adp of the SNF	Jun 23, 2025
1215 Kingsley Ave Opco Holdco LLC Organization · Jackson, NJ Created for acquisition, LLC, For-profit, Owned by another organization or individual	Indirect Ownership Interest	Dec 1, 2023	100%
Samira Khazravan Individual	Operational/Managerial Control	Oct 1, 2024
Samira Khazravan Individual	Adp of the SNF	Oct 1, 2024

Medicare enrollment records

Enrollment ID	State	Provider type	PAC ID	Details
O20240308000491	FL	Part a Provider - Skilled Nursing Facility	9739525197	Practice locations: Orange Park, FL

National Provider Directory

Locations

1215 Kingsley Ave
Orange Park, FL 32073
Phone (904) 269-8922

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Skilled Nursing Facility	314000000X			Yes

Addresses

Primary practice location

1215 Kingsley Ave
Orange Park, FL 32073-4631

Mailing address

1215 Kingsley Ave
Orange Park, FL 32073-4631
Phone (904) 269-8922

Other names

Aviata at Orange Park Doing business as

Electronic endpoints

Type	Endpoint	Use	Affiliation
CONNECT URL	https://65.196.137.118:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRResponse_Service	Other	Consulate Health Care

Other providers in Orange Park, FL

All providers in Orange Park, FL · Skilled Nursing Facility in Florida

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 9, 2025. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
Provider of Services files (CMS): certification status, beds and related CCNs.
Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.