1629185277 NPI number — NORTHEAST FLOIDA STATE HOSPITAL

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 1629185277 NPI number — NORTHEAST FLOIDA STATE HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST FLOIDA STATE HOSPITAL
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:
1629185277
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1820 WILD GRAPE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32003-7204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-269-2606
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1820 WILD GRAPE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGE PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32003-7204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-269-2606
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DUHAYLUNGSOD
Authorized Official First Name:
TORIBIO
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
SENIOR PHYSICIAN PSYCHIATRIST
Authorized Official Telephone Number:
904-259-6211

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X , with the licence number:  ME27968 , 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)





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