Healthcare Provider Details

I. General information

NPI: 1437674769
Provider Name (Legal Business Name): TRAUMA HEALING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8825 PERIMETER PARK BLVD STE 402
JACKSONVILLE FL
32216-1124
US

IV. Provider business mailing address

8825 PERIMETER PARK BLVD STE 402
JACKSONVILLE FL
32216-1124
US

V. Phone/Fax

Practice location:
  • Phone: 904-719-3312
  • Fax:
Mailing address:
  • Phone: 904-719-3312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH13530
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME102872
License Number StateFL

VIII. Authorized Official

Name: ZACHARY FLEMING
Title or Position: DIRECTOR
Credential:
Phone: 904-894-1736