1710154604 NPI number — JBA SVCS INC D/B/A IMMACULATE HOUSE AT COUNTRYSIDE

Table of content: (NPI 1710154604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710154604 NPI number — JBA SVCS INC D/B/A IMMACULATE HOUSE AT COUNTRYSIDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JBA SVCS INC D/B/A IMMACULATE HOUSE AT COUNTRYSIDE
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:
FOREST HILLS HOME AT PALM HARBOR
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:
1710154604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3823 PENDLEBURY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM HARBOR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34685-2670
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-934-4310
Provider Business Mailing Address Fax Number:
727-943-2075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2542 COUNTRYSIDE PINES DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEARWATER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33761-4921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-934-4310
Provider Business Practice Location Address Fax Number:
727-943-2075
Provider Enumeration Date:
05/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BOCK-ACKERMAN
Authorized Official First Name:
JOANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
ALF ADMINISTRATOR
Authorized Official Telephone Number:
727-934-4310

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL 11233 , 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)





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