1245695774 NPI number — AGAPE COMMUNITY HEALTH CENTER, INC

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 1245695774 NPI number — AGAPE COMMUNITY HEALTH CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AGAPE COMMUNITY HEALTH CENTER, 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:
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:
1245695774
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 KING ST
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:
32204-2410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-760-4940
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3101 UNIVERSITY BLVD S STE 200-207
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-2790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-760-4904
Provider Business Practice Location Address Fax Number:
904-647-2481
Provider Enumeration Date:
12/29/2015

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
MIA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
904-760-4904

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  N04000004094 , 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: 017234409 . 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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