1538687231 NPI number — NORTHEAST FLORIDA HEALTH SERVICES, INC.

Table of content: (NPI 1538687231)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538687231 NPI number — NORTHEAST FLORIDA HEALTH SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST FLORIDA HEALTH SERVICES, INC.
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:
FAMILY HEALTH SOURCE
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:
1538687231
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1205 S WOODLAND BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELAND
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32720-7466
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-202-6025
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 BEVILLE RD STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH DAYTONA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32119-1861
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-267-6214
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2017

Additional Information

Authorized Official

Authorized Official Last Name:
COLLIER
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
386-202-6025

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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