1992732473 NPI number — SENIOR CARE OF ST JOHNS OPERATOR LLC

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 1992732473 NPI number — SENIOR CARE OF ST JOHNS OPERATOR LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SENIOR CARE OF ST JOHNS OPERATOR LLC
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:
1992732473
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:
16 NORCROSS ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30075-3810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-255-1810
Provider Business Mailing Address Fax Number:
770-255-0059

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
189 SAN MARCO AVE
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:
32084-2733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-824-3326
Provider Business Practice Location Address Fax Number:
904-825-0593
Provider Enumeration Date:
06/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VAUGHAN
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
DANIEL
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
770-255-1810

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  SNF 1521096 , 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)





Copyright © 2007-2025 www.npivalidator.com