1376216945 NPI number — MENTAL HEALTH RESOURCE CENTER INC

Table of content: (NPI 1376216945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376216945 NPI number — MENTAL HEALTH RESOURCE CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MENTAL HEALTH RESOURCE 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:
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:
1376216945
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 19249
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:
32245-9249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-743-1883
Provider Business Mailing Address Fax Number:
904-743-5309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1636 SHADOWOOD LN STE 120
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:
32207-2187
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-725-9701
Provider Business Practice Location Address Fax Number:
904-725-9694
Provider Enumeration Date:
07/29/2021

Additional Information

Authorized Official

Authorized Official Last Name:
SOMMERS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
904-743-1883

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 060293115 . 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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