1467881292 NPI number — ST JOHNS WELFARE FEDERATION

Table of content: (NPI 1467881292)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467881292 NPI number — ST JOHNS WELFARE FEDERATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST JOHNS WELFARE FEDERATION
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:
1467881292
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
161A MARINE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32084-5154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-829-3475
Provider Business Mailing Address Fax Number:
904-808-9918

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
161B MARINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32084-5104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-829-3780
Provider Business Practice Location Address Fax Number:
904-829-2740
Provider Enumeration Date:
11/02/2013

Additional Information

Authorized Official

Authorized Official Last Name:
EDWARDS
Authorized Official First Name:
SUZANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
RESIDENT ACCOUNTS SUPERVISOR
Authorized Official Telephone Number:
904-584-1563

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL9470 , 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: 011032000 . 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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