Healthcare Provider Details

I. General information

NPI: 1558344978
Provider Name (Legal Business Name): ST VINCENTS AMBULATORY CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551616 US HIGHWAY 1
HILLIARD FL
32046-8281
US

IV. Provider business mailing address

551616 US HIGHWAY 1
HILLIARD FL
32046-8281
US

V. Phone/Fax

Practice location:
  • Phone: 904-845-3574
  • Fax: 904-845-7418
Mailing address:
  • Phone: 904-845-3574
  • Fax: 904-845-7418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP1440112
License Number StateFL

VIII. Authorized Official

Name: LINDA E GOODEN
Title or Position: AMG ADMINISTRATION
Credential:
Phone: 904-450-8288