Healthcare Provider Details

I. General information

NPI: 1073280988
Provider Name (Legal Business Name): FSL JAX BEACH TENANT LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2021
Last Update Date: 08/27/2021
Certification Date: 08/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 2ND AVE N
JACKSONVILLE BEACH FL
32250-3694
US

IV. Provider business mailing address

1240 E INDEPENDENCE ST STE 200
SPRINGFIELD MO
65804-4201
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-6479
  • Fax:
Mailing address:
  • Phone: 417-877-1717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: LESLIE DAWN CRAYTON
Title or Position: PROJECT MANAGER
Credential:
Phone: 417-877-1717