1205013232 NPI number — FLORIDA DEPARTMENT OF HEALTH

Table of content: (NPI 1205013232)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205013232 NPI number — FLORIDA DEPARTMENT OF HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA DEPARTMENT OF HEALTH
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:
6
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:
1205013232
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 UNIVERSITY BLVD., MC 75
Provider Second Line Business Mailing Address:
MC 75
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32211
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-253-2062
Provider Business Mailing Address Fax Number:
904-253-1942

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 KING ST
Provider Second Line Business Practice Location Address:
MC 75
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32204-2410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-253-2785
Provider Business Practice Location Address Fax Number:
904-253-1961
Provider Enumeration Date:
01/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WELLS
Authorized Official First Name:
KELLI
Authorized Official Middle Name:
T
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
904-253-2062

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6905561-01 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6905561-00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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