1205805421 NPI number — ORANGE PARK EXTENDED CARE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205805421 NPI number — ORANGE PARK EXTENDED CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORANGE PARK EXTENDED CARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE TERRACE AT FLEMING ISLAND
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205805421
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1125 FLEMING PLANTATION BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLEMING ISLAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32003-3389
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-541-3500
Provider Business Mailing Address Fax Number:
904-213-8338

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1125 FLEMING PLANTATION BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32003-3389
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-245-7620
Provider Business Practice Location Address Fax Number:
904-213-8338
Provider Enumeration Date:
03/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MARSH
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
BOOKKEEPER
Authorized Official Telephone Number:
386-255-1054

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  130471035 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 028478500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".