1558339028 NPI number — FLORIDA DEPARTMENT OF HEALTH

Table of content: (NPI 1558339028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558339028 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:
1558339028
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 S 4TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FERNANDINA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32034-4272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-548-1800
Provider Business Mailing Address Fax Number:
904-277-7286

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
86014 PAGES DAIRY ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YULEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-548-1880
Provider Business Practice Location Address Fax Number:
904-225-0850
Provider Enumeration Date:
03/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GLUCK
Authorized Official First Name:
CARE
Authorized Official Middle Name:
Authorized Official Title or Position:
HEALTH ADMINISTRATOR/HEALTH OFFICER
Authorized Official Telephone Number:
904-753-1231

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0279552 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 027955200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2026 www.npivalidator.com