1063180644 NPI number — AVECINA MEDICAL, PA

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 1063180644 NPI number — AVECINA MEDICAL, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVECINA MEDICAL, PA
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:
Provider Other Organization Name Type Code:
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:
1063180644
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4815 SWEETGRASS PL STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32224-0131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-367-3372
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2020 KINGSLEY AVE
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:
32073-5181
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-458-4013
Provider Business Practice Location Address Fax Number:
904-579-4289
Provider Enumeration Date:
08/31/2021

Additional Information

Authorized Official

Authorized Official Last Name:
MORETTI KIGHT
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
904-367-3372

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 006670011 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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