1629053962 NPI number — SV - JUPITER PROPERTIES INC

Table of content: (NPI 1629053962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629053962 NPI number — SV - JUPITER PROPERTIES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SV - JUPITER PROPERTIES 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:
DOCTORS LAKE OF ORANGE PARK
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:
1629053962
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
833 KINGSLEY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32073-4701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-269-2610
Provider Business Mailing Address Fax Number:
904-269-0873

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
833 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:
32073-4701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-269-2610
Provider Business Practice Location Address Fax Number:
904-269-0873
Provider Enumeration Date:
12/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
RHONDA
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
864-578-6599

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  SNF1237096 , 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: 022388300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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