MEDICARE: COURAGEOUS ENDEAVORS

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	251S00000X	Community/Behavioral Health Agency		FL

General Provider Information

NPI Number	:	1215226113
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COURAGEOUS ENDEAVORS

Provider Business Mailing Address
First Line	:	4803 RIVER POINT RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-2117
Country	:	US
Telephone Number	:	919-724-9157
Fax Number	:

Provider Business Practice Location Address
First Line	:	4803 RIVER POINT RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-2117
Country	:	US
Telephone Number	:	919-724-9157
Fax Number	:

Authorized Official
Title or Position	:	CO-EXECUTIVE DIRECTOR
Name	:	MR. WINSTON VICKERS
Credential	:
Telephone Number	:	919-724-9157

Provider Enumeration Date	:	03/31/2011
Last Update Date	:	03/31/2011

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