Healthcare Provider Details

I. General information

NPI: 1295549806
Provider Name (Legal Business Name): TIDES EDGE RECOVERY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2025
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 12TH ST S
JACKSONVILLE BEACH FL
32250-3422
US

IV. Provider business mailing address

75 12TH ST S
JACKSONVILLE BEACH FL
32250-3422
US

V. Phone/Fax

Practice location:
  • Phone: 904-685-9083
  • Fax:
Mailing address:
  • Phone: 904-685-9083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA YOST
Title or Position: PRESIDENT
Credential:
Phone: 904-778-6161