NPIMap

Organization Active NPI

Fort Walton Rehabilitation Center, LLC

  • Skilled Nursing Facility
  • Fort Walton Beach, FL
National Provider Identifier
1962788646
Registry record updated Sep 29, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
SNF11610951 Issued in FL
Legal business name
FORT WALTON REHABILITATION CENTER, LLC
Practice address
1 L B J Sr Dr
Fort Walton Beach, FL 32547-1163
Phone
(850) 863-2066
Fax
(850) 863-9006
NPI assigned
Oct 26, 2011
Last updated
Sep 29, 2014By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 29, 2014

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

Authorized official

Name
Mr. R. Mark Cronquist
Title
Manager
Phone
(404) 574-2100

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X FL
Skilled Nursing Facility 314000000X SNF11610951 FL Primary

Addresses

Primary practice location

1 L B J Sr Dr
Fort Walton Beach, FL 32547-1163

Mailing address

5887 Glenridge Dr
Suite 150
Atlanta, GA 30328-5574
Phone (404) 574-2100

Other identifiers 1

IdentifierTypeStateIssuer
004488800MedicaidFL

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120213000635 FL Part A Provider - Skilled Nursing Facility 2668639097 Practice locations: Fort Walton Beach, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1962788646. Details of each certification follow.

Skilled nursing facility certification: CCN 105295

Legal name
FORT WALTON REHABILITATION CENTER, LLC
Doing business as
FORT WALTON REHABILITATION CENTER
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Dec 16, 1979
Last certification
Mar 28, 2024
Beds
120
Ownership / control type
Limited Liability Corporation
Multi-facility organization
Southern Health Care Management
Organization structure
LLCProprietary
Incorporated
Oct 26, 2011 in DE
Enrollment address
1 LBJ Sr Drive
Fort Walton Beach, FL 32547-1163
Nursing home name
FORT WALTON REHABILITATION CENTER, LLC
Affiliated entity
SOVEREIGN HEALTHCARE HOLDINGS

Care Compare: Nursing home

Medicare Care Compare
Listed as
Fort Walton Rehabilitation Center, LLCCCN 105295 · All quality measures
Overall star rating
5 of 5
Health inspections
5 of 5
Staffing
3 of 5
Quality measures
5 of 5
Type
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified
Dec 16, 1979
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
120103.9 residents per day on average
Chain
Sovereign Healthcare Holdings43 facilities in the chain

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
10D0701836Fort Walton Rehabilitation Center LLC1 LBJ Senior Dr, Fort Walton Beach, FL 32547Certificate of waiverAug 31, 2026

National Provider Directory

National Provider Directory

Networks

  • Freedom Health HMO NetworkPlans: Freedom Platinum Rewards Plan Rx (HMO) (H5427-102-000, H5427); Freedom VIP Care (HMO C-SNP) (H5427-070-000, H5427); Freedom VIP Rewards (HMO C-SNP) (H5427-108-000, H5427); Freedom VIP Rewards (HMO C-SNP) (H5427-099-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-107-000, H5427); Freedom Máximo (HMO-POS) (H5427-113-000, H5427); Freedom Savings Plan (HMO) (H5427-052-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-096-000, H5427); Freedom Platinum Rewards Plan Rx (HMO) (H5427-105-000, H5427); Freedom Medi-Medi Full (HMO D-SNP) (H5427-087-000, H5427)…
  • Optimum HealthCare HMO NetworkPlans: Optimum Diamond Rewards (HMO C-SNP) (H5594-028-000, H5594); Optimum Diamond (HMO C-SNP) (H5594-036-000, H5594); Optimum Diamond Rewards (HMO C-SNP) (H5594-034-000, H5594); Optimum Diamond Rewards COPD (HMO C-SNP) (H5594-029-000, H5594); Optimum Platinum Plan (HMO) (H5594-002-000, H5594); Optimum Gold Plus Plan (HMO) (H5594-032-000, H5594); Optimum Diamond Savings COPD (HMO C-SNP) (H5594-031-000, H5594); Optimum Diamond Savings (HMO C-SNP) (H5594-030-000, H5594); Optimum Diamond Rewards COPD (HMO C-SNP) (H5594-035-000, H5594)

Ownership & related parties

All disclosed owners & managing parties 23

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

NameRoleSinceShare
PH-MC, LLC Organization, Atlanta, GA LLC Adp of the SNF Jun 1, 2013
Susan Kaar Individual Managing Control - Governing BodyVP of Compliance and Quality MGMT Jun 1, 2013
Adp of the SNF Jun 1, 2013
Sovereign Healthcare Disbursements LLC Organization, Casselberry, FL LLC Adp of the SNF Jun 1, 2013
Orix Real Estate Capital LLC Organization, Dallas, TX LLC 5% Or Greater Security Interest Jan 1, 2025 100%
Fate Brown Individual Managing Control - Governing BodyVice President of Operations May 1, 2017
Adp of the SNF May 1, 2017
John Mangine Individual Operational/Managerial Control Jun 25, 2012
Adp of the SNF Jun 25, 2012
Indirect Ownership Interest Jun 25, 2012 3%
Southern Healthcare Management LLC Organization, Casselberry, FL LLC, Management services company, For-profit Operational/Managerial Control Jun 1, 2013
Adp of the SNF Dec 3, 2025
Individual Adp of the SNF Jun 1, 2013
Ashley Lauren Hodge Individual Operational/Managerial Control Sep 18, 2020
Adp of the SNF Sep 18, 2020
Michelle Kelly Individual Adp of the SNF Feb 1, 2018
Donald K Melton Individual Operational/Managerial Control Feb 15, 2009
Adp of the SNF Feb 15, 2009
William Notermann Individual Operational/Managerial Control Jan 1, 2025
Adp of the SNF Jan 1, 2025
WDW Trust Organization, Santa Rosa Beach, FL Adp of the SNF Jun 1, 2013
Sovereign Healthcare Holdings LLC Organization, Atlanta, GA LLC, For-profit, Chain home office, Owned by another organization or individual Direct Ownership Interest Feb 1, 2012 100%
Panhandle Nursing Care, Inc. Organization, Casselberry, FL Corporation, Owned by another organization or individual 5% Or Greater Security Interest Jun 1, 2013 100%
Adp of the SNF Jun 1, 2013
Royce M Cronquist Individual Operational/Managerial Control Feb 1, 2018
Adp of the SNF Feb 1, 2018
PH-JN, LLC Organization, Atlanta, GA LLC Adp of the SNF Jun 1, 2013
John J Notermann Business TR Organization, Atlanta, GA Owned by another organization or individual Indirect Ownership Interest Nov 12, 2017 82.5%
Forvis Mazars LLP Organization, Springfield, MO Adp of the SNF Jan 1, 2025
Dawn Chery Individual Managing Control - Governing BodyChief Nursing Officer Jun 8, 2017
Adp of the SNF Jun 8, 2017
Cronquist 2015 Family TR Organization, Atlanta, GA For-profit, Owned by another organization or individual Indirect Ownership Interest Dec 31, 2015 14.5%
Steven S Donchey Individual Operational/Managerial Control Dec 31, 2025
Adp of the SNF Dec 31, 2025
HSP Panhandle, LLC Organization, Casselberry, FL LLC, Owned by another organization or individual 5% Or Greater Security Interest Jun 1, 2013 100%
Adp of the SNF Jun 1, 2013

Owners & managing parties with NPI records 1

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

Facilities with the same owner 41

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 41

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 2

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

NPI Registry JSON

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

{
    "created_epoch": "1319587200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1411948800000",
    "number": "1962788646",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5887 GLENRIDGE DR",
            "address_2": "SUITE 150",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303285574",
            "telephone_number": "404-574-2100",
            "fax_number": "404-574-2105"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 L B J SR DR",
            "city": "FORT WALTON BEACH",
            "state": "FL",
            "postal_code": "325471163",
            "telephone_number": "850-863-2066",
            "fax_number": "850-863-9006"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FORT WALTON REHABILITATION CENTER, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-10-26",
        "last_updated": "2014-09-29",
        "status": "A",
        "authorized_official_last_name": "CRONQUIST",
        "authorized_official_first_name": "R.",
        "authorized_official_middle_name": "MARK",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "404-574-2100",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "FL",
            "license": null,
            "primary": false
        },
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "FL",
            "license": "SNF11610951",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "004488800",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Walton Beach, FL

Sources for this page

Verify at the official NPI Registry.