Healthcare Provider Details

I. General information

NPI: 1790519775
Provider Name (Legal Business Name): TIDES EDGE RECOVERY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2024
Last Update Date: 08/30/2024
Certification Date: 08/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 11TH AVE N
JACKSONVILLE BEACH FL
32250-7224
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 Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

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