1902162555 NPI number — PHYSICIANS HEALTH CENTER OF NORTH FLORIDA

Table of content: (NPI 1902162555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902162555 NPI number — PHYSICIANS HEALTH CENTER OF NORTH FLORIDA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIANS HEALTH CENTER OF NORTH FLORIDA
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:
1902162555
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3161 BOSTON HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTICELLO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32344-4401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-236-4619
Provider Business Mailing Address Fax Number:
904-367-0290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4000 SAINT JOHNS AVE
Provider Second Line Business Practice Location Address:
SUITE 35
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32205-9357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-236-4619
Provider Business Practice Location Address Fax Number:
904-367-0290
Provider Enumeration Date:
04/09/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LITTLEFIELD
Authorized Official First Name:
JAY
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
CHIROPRACTOR/MANAGING MEMBER
Authorized Official Telephone Number:
904-236-4619

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH9979 , 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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