MEDICARE: LP JACKSONVILLE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	313M00000X	Nursing Facility/Intermediate Care Facility	SNF10800961	FL
2	314000000X	Skilled Nursing Facility	SNF10800961	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154644912
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LP JACKSONVILLE, LLC

Provider Business Mailing Address
First Line	:	2061 HYDE PARK RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-3815
Country	:	US
Telephone Number	:	904-786-7331
Fax Number	:	904-786-4034

Provider Business Practice Location Address
First Line	:	2061 HYDE PARK RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-3815
Country	:	US
Telephone Number	:	904-786-7331
Fax Number	:	904-786-4034

Authorized Official
Title or Position	:	CFO
Name	:	MR. JOHN HARRISON
Credential	:
Telephone Number	:	502-568-7800

Provider Enumeration Date	:	03/09/2010
Last Update Date	:	03/01/2012

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