MEDICARE: NORTHEAST FLORIDA HEALTH SERVICES, INC.

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	261QF0400X	Federally Qualified Health Center (FQHC)

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	:	1396282208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST FLORIDA HEALTH SERVICES, INC.

Provider Business Mailing Address
First Line	:	1205 S WOODLAND BLVD STE 3
Second Line	:
City	:	DELAND
State	:	FL
Zip	:	32720-7464
Country	:	US
Telephone Number	:	386-202-6025
Fax Number	:	386-269-1847

Provider Business Practice Location Address
First Line	:	801 BEVILLE RD STE 101&102
Second Line	:
City	:	SOUTH DAYTONA
State	:	FL
Zip	:	32119-1860
Country	:	US
Telephone Number	:	386-267-6214
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	REBECCA COLLIER
Credential	:
Telephone Number	:	386-202-6025

Provider Enumeration Date	:	01/30/2017
Last Update Date	:	08/10/2021

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